Drug Metab Drug Interact 2014; 29(3): 143151

Review

Zahra Merali, Stephanie Ross and Guillaume Par*

The pharmacogenetics of carboxylesterases: CES1

and CES2 genetic variants and their clinical effect
Abstract: Human carboxylesterase 1 (CES1) and carboxyl
esterase 2 (CES2) are serine esterases responsible for the
hydrolysis of ester and amide bonds present in a number
of pharmaceutical products. Several common genetic
variants of the CES1 and CES2 genes have been shown to
influence drug metabolism and clinical outcomes. Poly
morphisms of the CES1 gene have been reported to affect
the metabolism of dabigatran etexilate, methylphenidate,
oseltamivir, imidapril, and clopidogrel, whereas variants
of the CES2 gene have been found to affect aspirin and
irinotecan. Although the findings of these studies may
be preliminary, they demonstrate the potential clinical
utility of CES polymorphisms; however, more research is
required, especially with respect to CES2. In this review,
we outline the functional, molecular, and genetic proper
ties of CES1 and CES2, and highlight recent studies that
have shown relations between CES1 and CES2 variants and
contemporary pharmacotherapy.
Keywords: aspirin; carboxylesterase; carboxylesterase 1;
carboxylesterase 2; clopidogrel; dabigatran etexilate;
*Corresponding author: Guillaume Par, Population Health
Research Institute, McMaster University, Hamilton General Hospital
Campus, DB-CVSRI, 237 Barton Street East, Room C3103, Hamilton,
Ontario, Canada L8L 2X2, Phone: +1 905 527 4322 ext. 40377,
Fax: +1 905 296 5806, E-mail: pareg@mcmaster.ca
Zahra Merali: Royal College of Surgeons in Ireland, Dublin, Ireland
Stephanie Ross: Population Health Research Institute, Hamilton
Health Sciences, McMaster University, Hamilton, Ontario, Canada;
Population Genomics Program, Chanchlani Research Centre,
McMaster University, Hamilton, Ontario, Canada; and Department
of Clinical Epidemiology and Biostatistics, McMaster University,
Hamilton, Ontario, Canada
Guillaume Par: Population Health Research Institute, Hamilton
Health Sciences, McMaster University, Hamilton, Ontario, Canada;
Population Genomics Program, Chanchlani Research Centre,
McMaster University, Hamilton, Ontario, Canada; Department
of Clinical Epidemiology and Biostatistics, McMaster University,
Hamilton, Ontario, Canada; Department of Pathology and Molecular
Medicine, McMaster University, Hamilton, Ontario, Canada; and
Thrombosis and Atherosclerosis Research Institute, Hamilton
Health Sciences, McMaster University, Hamilton, Ontario, Canada
gene function; imidapril; irinotecan; methylphenidate;
oseltamivir; pharmacogenetics.
DOI 10.1515/dmdi-2014-0009
Received February 18, 2014; accepted May 16, 2014; previously pub-
lished online July 2, 2014
Introduction
It is widely recognized that there is substantial individual
variation in the response to pharmacologic therapies.
There are many factors that contribute to this variabil
ity, such as drug compliance and drug-drug interactions.
Genetic factors have emerged as important predictors of
drug metabolism. Pharmacogenetics is the study of how
genetic variants influence drug response. The ultimate
goal of pharmacogenetics is to develop novel ways of min
imizing harmful drug effects and optimizing care for indi
vidual patients by incorporating their genetic information.
Recent studies have suggested that the presence of func
tional genetic variants of carboxylesterase 1 (CES1) and car
boxylesterase 2 (CES2) influence the pharmacokinetic and
pharmacodynamic properties of several drugs. The CES1 and
CES2 genes encode enzymes that are the principal contribu
tors to hydrolysis of pharmacological agents that contain
ester or amide bonds [1]. Thus, a better understanding of
how genetic polymorphisms of CES1 and CES2 influence
drug response may ultimately lead to personalized tailoring
of pharmacological therapies. The purpose of this report is
to explore the functional, molecular, and genetic properties
of CES1 and CES2. We will also selectively review pharmaco
genetic evidence of the impact of CES1 variants on the phar
macologic effect of dabigatran etexilate, methylphenidate
(MPH), oseltamivir, imidapril, and clopidogrel, as well as the
effect of CES2 variants on aspirin and irinotecan. While we
have focused on drugs for which most data are available, we
note that CES1 has been reported to affect the metabolism of
trandolapril, enalapril, ramipril [2], olmesartan, medoxomil
[3], propranolol [4], ticlopidine [5], heroin, and cocaine [6].
Similarly, CES2 has also been reported to affect the metabo
lism of orlistat [7], gemcitabine [8], and doxazolidine [9].

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144Merali etal.: The pharmacogenetics of carboxylesterases: CES1 and CES2
Function, isoenzymes, and structure
of carboxylesterases
Human carboxylesterases (CES) are serine esterases and
members of the --hydrolase family [10]. They are local
ized in the endoplasmic reticulum and are found in a
broad range of tissues, which include the placenta, brain,
intestine, and liver [11]. These enzymes are responsible for
the hydrolysis of the ester or amide bonds of exogenous
compounds [10]. As ester bonds increase lipophilicity
and tissue availability, these bonds are commonly found
in therapeutic prodrugs, and hydrolysis of such bonds
results in water-soluble carboxylic acid and alcoholic
metabolites that may be safely excreted [12].
There are at least five known isoenzymes of CES
(CES1CES5) [13], as well as a newly discovered isoenzyme
(CES6). The CES isoenzymes share approximately 40%
50% amino acid sequence identity [14], and vary in their
substrate specificity and tissue expression. The CES1 iso
enzymes consist of many subfamilies (CES1ACES1G). The
CES1A and CES1B subfamilies are the major forms found
in humans. CES1A1 is 50-fold more concentrated in the
liver than CES1B, making it most likely responsible for the
hydrolysis of most ester-containing substrates [12]. In fact,
the CES1A isoenzyme is the tenth most abundant protein
expressed in the liver [15]. The CES1 isoenzyme hydro
lyzes substrates with small alcoholic groups and large
acyl groups, such as dabigatran etexilate, MPH, oseltami
vir, imidapril, and clopidogrel. In contrast, the CES2
isoenzyme hydrolyzes substrates with mirroring charac
teristics, such as aspirin and irinotecan [12]. Furthermore,
whereas CES1 is located in the liver, CES2 is found mainly
in the small intestine and liver [16]. The CES3 isoenzyme
is expressed mainly in the liver and gastrointestinal tract,
and at a significantly lower level than CES1 and CES2. As
CES3 is the murine ortholog of CES1, CES3 model systems
corroborate the effects of CES1 [17].
The CES4 and CES5 isoenzymes have lesser expression
in humans. CES4 is a pseudogene of CES1, referred to as
CES1A3 or CES1P1 and will be discussed later (refer to the
subsection on The genetics of CES1 and CES2). CES5 is pre
dominantly expressed in peripheral tissues, including the
brain, kidney, lung, and testis. It is located within a protein
complex present in mammalian male epididymal fluids and
has also been identified in the human brain where it is most
likely localized in the cerebrospinal fluid or other fluids of
the brain. Human CES5 is thought to play a role in catalyz
ing lipid transfer reactions within male reproductive fluids
and in protecting neural tissue from drugs and xenobiotics.
Structurally, human CES5 shares key conserved sequences
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and structures with human CES1 [18]. Recently, CES6, a new
class of CES isoenzymes, has been identified. Human CES6-
like transcripts have been previously reported to be widely
distributed in the body; however, they are mainly found in
specific regions of the brain, such as the cerebellum. CES6
is thought to play a role in the detoxification of drugs and
xenobiotics in neural and other tissues in the body, as well
as in cerebrospinal fluid [18].
All CES have a similar peptidic structure with an
N-terminal signal peptide of 1722 amino acid residues,
including a hydrophobic amino acid [13]. CES have four
characteristic cysteine (Cys) residues that are involved in
specific disulfide bonds, and Cys98 is the most highly con
served residue in many of the CES enzymes. Post-transla
tional modification of CES1 includes cleavage of the signal
sequence, which occurs between the bulky amino acid
residue (Trp17) and the small neutral residue (Gly18) [19,
20]. Three crystal structures of CES1 in humans have been
characterized to date and indicate that the CES exists in
a trimer-hexamer equilibrium [21]. Each monomer com
prises a catalytic domain, an / domain, and a regula
tory domain. The catalytic triad Ser221-His468-Glu352
forms a 1015 deep hydrophobic pocket at the interface
of the three domains and makes up the active site [11].
Three consecutive glycine residues are also located in the
active site of CES1 (Gly141143), which create an oxyanion
hole. The catalytic triad and oxyanion hole are speculated
to stabilize substrate-enzyme intermediates, and thus are
essential to CES1 functionality [11].
The CES enzymes also play a key role in lipid metab
olism. Indeed, they are responsible for breaking down
endogenous substrates, such as triacylglycerol, 2-arachi
donylglycerol, and cholesteryl esters, in addition to xeno
biotic substrates. CES1 hydrolyzes the aforementioned
substrates by releasing an alcohol substituent to form a
fatty acyl-enzyme intermediate that reacts with water
and releases an acyl group-containing molecule. CES1 is
involved in the de-esterification and trans-esterification
of lipids as it has cholesterol transferase activity, which
enables the formation of cholesteryl esters in the pres
ence of free cholesterol [22]. It has also been reported that
regulation of macrophage reverse cholesterol transport
(mRCT) is facilitated by hydrolytic CES metabolism of chol
esteryl esters found within cytoplasmic lipid droplets [23].
Indeed, overexpression of CES1 in mouse macrophages
resulted in a decrease of atherosclerosis and lesion necro
sis while increasing mRCT. In addition, nuclear receptors,
such as peroxisome proliferator-activated receptors, have
a role in downregulating CES1 promoter activity. Fatty
acids, produced under normal and pathological condi
tions, act as ligands for these nuclear receptors and leads
 Merali etal.: The pharmacogenetics of carboxylesterases: CES1 and CES2145

to an increase in fatty acid concentrations, which inhibits
the hydrolytic activity of CES enzymes. Furthermore, the
SOS Sib Pair Study, a study that consisted of 154 nuclear
families with body mass index (BMI)-discordant sib pairs
(BMI difference, 10 kg/m2) [24], has demonstrated a cor
relation between obesity and CES1 expression in adipose
tissue of 732 study participants. CES1 expression was
shown to be higher in obese females and males than that
in their lean sibling of the same sex. In obese patients,
diet-induced weight loss resulted in decreased CES1
expression. It has been speculated that the expression of
CES1 mRNA in adipose tissue is linked with measures of
adiposity and metabolic function, such as waist circum
ference, homeostasis model assessment-insulin resist
ance, triglyceride level, and plasma insulin level. This
suggests that CES1 has a fundamental role in lipid metab
olism and may contribute to the incidence of obesity and
type 2 diabetes mellitus. Nonetheless, no CES1 or CES2
polymorphisms were associated with lipids levels in the
Global Lipids Genetics Consortium meta-analysis (data
not shown; n=188,577) [25], which could be due to effects
of CES on lipid fractions other than the ones studied in
genetic association studies.
The genetics of CES1 and CES2
The CES1 gene lies on chromosome 16q12.2 and contains
14 exons [23]. Ghosh and Natarajan [24] identified a CAAT
box, a GC-rich sequence, several SP1 binding sites, and
three putative peroxisome proliferator response ele
ments in the promoter region of the CES1 gene. Alternative
splicing results in three CES1 isoforms: CES1A1, CES1A2,
and CES1A3. Although the CES1A1 and CES1A2 isoforms
are functional, CES1A3 is a pseudogene due to a prema
ture stop codon located on exon 3. With the exception of
exon 1 and promoter regions, CES1A1 and CES1A2 have an
identical structure [10]. However, most of the CES1 protein
in the liver is the product of CES1A1, as the transcription
efficiency of the CES1A2 gene is only 2% of CES1A1 [26].
This is most likely because the Sp1 and CCAAT/enhancer
binding protein can bind to each responsive element of
the CES1A1 promoter but cannot bind to the responsive
element of the CES1A2 promoter. Both promoters are
TATA-less, which is a characteristic shared by other CES
promoters [27, 28]. In contrast, less is known about CES2.
CES2 lies on chromosome 16q22.1 and consists of 12 exons.
The alternative splicing of CES2 results in two isoforms.
Figure 1 illustrates the genetic regions of CES1 and CES2,
and shows the RefSeq isoforms.
CES1 mRNA expression is influenced by the CES1A3
(CES1P1) pseudogene, located in the vicinity of CES1.
CES1A3 results from gene duplication and has been
shown to increase the production of CES1 and, hence,
CES1 activity [22]. It has been reported that the daughter
copy of the gene is transcribed at a lower level than the
mother copy and the transcripts of CES1A3, and its func
tional counterpart can compete for the same transacting
factors involved in mRNA degradation [22]. Thus, the high
levels of transcripts generated from CES1A3 may protect
the transcript of the functional homolog from degradation
and thereby increase its translation.
The expression of CES enzymes is altered by xeno
biotics and developmental age. For example, pharmaceu
tical agents such as dexamethasone and phenobarbital
cause a moderate induction of both CES1 and CES2 in
human hepatocytes. In contrast, interleukin-6 leads to
downregulation of liver CES expression [29]. It has also
been shown that the expression of CES increases with
increasing age, and animal models have shown that the
intrinsic clearance rate of pharmaceuticals involved in
the CES1 metabolism was half as much in younger rats as
compared with adult rats [30]. Furthermore, Yang etal.
[31] analyzed a total of 104 individual liver samples for

CES1

CES2

Figure 1Genetic context of CES1 and CES2.

*RefSeq isoforms are illustrated. Adapted from UCSC Genome Browser on Human February 2009 (GRCh37/hg19) Assembly.

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146Merali etal.: The pharmacogenetics of carboxylesterases: CES1 and CES2
the expression of CES1 and CES2, grouping their sub
jects into adults (>18 years), children (010 years), and
fetuses (82224 gestation days). It was observed that
fetuses showed lower CES expression than children, and
children had lower CES expression than adults, which
indicates that age may have an effect on the observed
variability in CES1 and CES2 activity and their relation
to drug efficacy.
The pharmacogenetics of the CES1
genotype
A summary of the significant CES1 and CES2 associations
discussed in this section are provided in Table 1. Although
data were only available for rs2244613, rs8192935, and
rs3785161, moderate linkage disequilibrium was observed
[40] with pairwise r2 ranging from 0.05 to 0.40 using
1000G data.
Dabigatran etexilate
Dabigatran etexilate is novel oral anticoagulant used
in the prevention of stroke among atrial fibrillation
patients [41]. Although warfarin is presently the main
stay oral anticoagulant, there are several limitations to
its use, including a narrow therapeutic window, need
for frequent coagulation monitoring, and slow onset
and/or offset actions. Dabigatran etexilate is offered
as an alternative to warfarin as it has a rapid onset of
action and does not require frequent monitoring [42].
Dabigatran etexilate is a prodrug that is rapidly con
verted to its active metabolite, the direct thrombin
inhibitor dabigatran, by esterases, including the CES1
enzyme [43]. The cytochrome P450 enzymes and other
oxidoreductases are not involved in this process. The
maximum plasma concentrations of dabigatran etex
ilate occur within 13h after dosing, and 80% is elimi
nated through the renal excretion pathway. As CES1 is
the primary enzyme involved in the biotransformation
of dabigatran etexilate, it has been thought that the vari
ability in blood concentrations may be a result of CES1
genetic polymorphisms.
Recently, Par et al. [32] conducted a genome-wide
association study of both genetic and pharmacokinetic
data of 2944 participants from the Randomized Evalu
ation of Long-term Anticoagulation Therapy (RE-LY).
The authors reported that the CES1 small nuclear poly
morphism (SNP) rs2244613 was associated with a 15%
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decrease in trough concentrations of dabigatran etexilate
per allele, and was associated with peak concentrations
at genome-wide significance (p<9108), as well as dem
onstrating a gene-dose effect. The authors also reported
a significant association between rs2244613 (CES1)
and risk of any bleeding (OR=0.67, 95% CI 0.550.82;
p=7105) in dabigatran-treated participants, with a con
sistent but non-significant lower risk of major bleeding
(OR=0.66, 95% CI 0.431.01). There was no association
with ischemic events, and rs8192935 was not associated
with bleeding or ischemic events. These results are clini
cally significant as the relative risk of bleeding was 0.73
(95% CI 0.630.86) for 32.8% of the RE-LY participants
that are rs2244613 minor allele carriers versus non-car
riers, whereas the reported relative risk of bleeding was
0.86 (95% CI 0.810.93) for the lower (110mg bid) versus
higher dose (150 mg bid) of dabigatran etexilate in the
overall study [44]. These results emphasize the potential
importance of exploring the pharmacogenetic effect of
CES1 on drugs with a low therapeutic index, as well as
the key role of CES enzymes in the biotransformation of
dabigatran etexilate.
Methylphenidate
MPH is a widely prescribed psychostimulant for the treat
ment of attention deficit/hyperactivity disorder (ADHD),
a common childhood-onset psychiatric disorder. Approx
imately 49%66% of ADHD cases progress to chronic
adulthood ADHD, which leads to severe impairments
in school, work, family, and social functioning [45].
However, 30% of patients receiving psychostimulants,
such as MPH, are either non-responders or intolerant
to the treatment [46]. It is thought that the intraindivid
ual variation in response to MPH may be attributable to
CES1 variants [1]. CES1 is the principal enzyme responsi
ble for the rapid de-esterification of MPH to its inactive
metabolite, ritalinic acid [47]. CES1 de-esterification is
stereoselective and favors hydrolysis of the L-isomer (over
D-MPH).
Zhu etal. [1] conducted a pharmacokinetic study and
identified two SNPs (rs71647871 and rs71647872) associ
ated with CES1 function and MPH concentrations. The
rs71647871 SNP in exon 4 results in a non-conservative
amino acid substitution of glycine 143 to glutamic acid
(Gly143Glu), whereas the rs71647872 SNP (a deletion
in exon 6) results in frameshift mutation, p.Asp260fs,
and truncation at a premature stop codon. The authors
reported that both polymorphisms were associated with
a marked decrease in the catalytic function of CES1.
 Table 1Significant CES genetic variants and the reported effects on drug metabolism.

Drugs Rs ID Reference Alternative Function Enzymatic activity (in vitro) Outcomes (in vivo and clinical)
allele allele

CES1
Dabigatran etexilate [32] rs8192835 C T Intronic Not assessed Decreased peak concentrations
rs2244613 G T Intronic Not assessed Decreased trough concentrations, and consistent
yet non-significant for the risk of major bleeding
Methylphenidate [1, 33] rs71647871 G A Missense Decreased CES1 carriers required lower doses of MPH for
symptom reduction (p=0.022)
rs71647872 T Frameshift Decreased Rare mutation that has not been fully assessed
because of minor clinical relevance
Oseltamivir [34, 35] rs71647871 G A Missense Decreased Not yet assessed but decreased active metabolite
concentration has been predicted

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rs121912777 G A Missense Not assessed Decreased active metabolite concentration
Imidapril [36] rs3785161 A C Missense Higher promoter activity Reduction in systolic blood pressure higher
(may contribute to increased among CES1 carriers compared with non-carriers

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enzymatic activity) (p=0.0184)
Clopidogrel [37] rs71647871 G A Missense Decreased Increased active metabolite concentration
CES2
Aspirin [38] rs ID could not be determined with A T Missense Decreased Not assessed
certainty; refer to Tang et. al. [38]
Irinotecan [39] rs72547531 C T Missense Decreased AUC ratio decreased
rs72547532 A G Missense Decreased AUC ratio decreased

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Merali etal.: The pharmacogenetics of carboxylesterases: CES1 and CES2147
148Merali etal.: The pharmacogenetics of carboxylesterases: CES1 and CES2
The minor allele frequency of rs71647871 was estimated
to be 3.7%, 4.3%, and 2.0% in European, African, and
Hispanic populations, respectively. However, the SNP
rs71647872 appeared to be rare, with a frequency of <1%.
As these polymorphisms have a low frequency, they
might not have a substantial impact at the population
level, although they might be important to individual
carriers. Nemoda etal. [33] also confirmed the associa
tion between rs71647871 and reduced CES1 activity. They
explored the genetic effect of rs71647871 among 122
ADHD children treated with MPH. Although the authors
reported that there were no significant associations
between rs71647871 carrier status and response accord
ing to the ADHD rating scale, carriers of the variant allele
who were identified as responders required lower doses
of MPH for symptom reduction (p=0.022). However,
this study had a relatively small sample size and may
have not had enough power to detect a genetic effect.
As younger children have decreased levels of CES1 enzy
matic activity [29], and ADHD is a disorder especially
prevalent in this population, MPH drug toxicities may
be a particular concern when treating these individuals;
however, more research is required to substantiate this
hypothesis.
Oseltamivir
Oseltamivir is widely used in the treatment and prevention
of influenza A and B virus infections, and is recommended
by the World Health Organization during influenza pan
demics [48]. Oseltamivir is an ethyl ester prodrug, and
the CES1 enzyme is involved in the biotransformation
of oseltamivir to its active metabolite, oseltamivir car
boxylate. The active metabolite acts as a neuraminidase
inhibitor that inhibits the viral neuraminidase protein and
prevents viral reproduction [49]. Several pharmacokinetic
studies have demonstrated variability in the response to
oseltamivir [50, 51].
Zhu et al. [34] investigated whether the rs71647871
SNP influenced the hydrolysis of oseltamivir to oseltami
vir carboxylate, using cell lines that expressed wild-type
and mutant CES1. The authors reported that the Vmax of
rs71647871 mutant cells was approximately 25% lower than
that of wild-type CES1. Tarkiainen et al. [35] assessed the
pharmacokinetic effect of CES1 variants on oseltamivir
among healthy volunteers by using the missense rs121912777
SNP. Heterozygous rs121912777 allele carriers had 18%
increased oseltamivir area under the plasma concentra
tion-time curve (AUC) (p=0.025) and 23% smaller carbox
ylate-to-oseltamivir AUC as compared with non-carriers.
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These studies suggest that genetic variants of CES1 may
decrease the metabolism of oseltamivir and hinder prodrug
activation, which may result in altered therapeutic effects.
However, there is a need for large, clinical pharmacoge
netic studies assessing the effect of the CES1 variants and
oseltamivir treatment response before any conclusions can
be made on the clinical utility of CES1 genotyping.
Imidapril
Imidapril is an angiotensin-converting enzyme inhibi
tor that is used to reduce blood pressure by antagonizing
the production of angiotensin II from angiotensin I, thus
inhibiting the renin-angiotensin-aldosterone system [36].
Imidapril is a prodrug, and CES1 is the primary enzyme
that is involved in converting imidapril to the active
metabolite, imidaprilat [52].
Geshi et al. [36] assessed the association between
the rs3785161 SNP (CES1A2) and responsiveness to
imidapril among 105 hypertensive Japanese patients.
After 8 weeks of imidapril treatment, the patients were
classified as responders or non-responders on the
basis of the following: a decline in either systolic blood
pressure (SBP) <140mmHg and diastolic blood pressure
(DBP) <90mm Hg; SBP decreased by 20mm Hg and DBP
decreased by 10 mm Hg; or the mean blood pressure
decreased by 13mm Hg. The authors reported that the
responder rate was significantly higher among rs3785161
allele carriers as compared with non-carriers (p=0.0331).
Accordingly, the reduction in systolic blood pressure was
significantly higher among carriers as compared with
non-carriers (p=0.0184). The authors also observed that
the rs3785161 SNP had significantly higher promoter activ
ity and suggests that the higher transcriptional activity of
CES1 may contribute to increased enzymatic activity.
Clopidogrel
Dual antiplatelet therapy with clopidogrel and aspirin is
the current standard of care for the prevention of adverse
cardiovascular outcomes in patients with acute coronary
syndromes or percutaneous coronary intervention [53].
Clopidogrel is a prodrug that irreversibly binds to platelet
ADP P2Y12 receptor, thus inhibiting platelet aggregation.
Clopidogrel is oxidized by a two-step process through the
hepatic cytochrome P450 enzyme pathway [54]. However,
85% of clopidogrel is rapidly hydrolyzed to its inactive
metabolite, clopidogrel carboxylic acid, by CES1 [38]. Cur
rently, most of the research on the pharmacogenetic effect
 Merali etal.: The pharmacogenetics of carboxylesterases: CES1 and CES2149
of clopidogrel has focused primarily on the genetic varia
tion of the CYP450 enzymes, with a very strong emphasis
on CYP2C19. However, these variants only account for 12%
of the variability in platelet aggregation [55].
Lewis et al. [37] assessed the association between
the rs71647871 SNP and bioactive metabolite levels, on-
clopidogrel ADP-stimulated platelet aggregation, and car
diovascular outcomes among 566 participants from the
Pharmacogenomics of Anti-Platelet Intervention (PAPI)
study and 350 patients with coronary heart disease (CHD)
treated with clopidogrel. Previous studies have demon
strated that carriers of the rs71647871 SNP have decreased
CES1 catalytic activity [1]. The authors reported that CES1
rs71647871 allele carriers had significantly higher levels
of active clopidogrel metabolite (p=0.001) and better
clopidogrel response as measured by ADP-stimulated
platelet aggregation in the PAPI cohort (p=0.003) and in
clopidogrel-treated CHD patients (p=0.03). There was no
association between CES1 rs71647871 allele carriers and
baseline measures of platelet aggregation or CVD out
comes in either cohort. Owing to the rarity of variant allele
carriers, there may not have been enough power to detect
a genetic effect. These results suggest that the genetic
variants of CES1 may be associated with increased plasma
concentrations of clopidogrel and may increase the risk of
potential toxic or adverse side effects.
The pharmacogenetics of the CES2
genotype
Aspirin
Aspirin (acetylsalicylic acid) is an antiplatelet agent that
is used in the treatment and prevention of cerebrovascular
and cardiovascular events [56]. Aspirin irreversibly acety
lates the enzyme cyclooxygenase-1 and inhibits the produc
tion of platelet-derived thromboxane A2. Although aspirin
is commonly prescribed for the primary and secondary
prevention of cardiovascular disease, approximately
25%40% of patients experience aspirin resistance [57].
Aspirin is an ester that is hydrolyzed predominately by
CES2 in the gastrointestinal tract to form the active metab
olite salicylic acid. To date, there have been only a few
studies assessing the association between CES2 genetic
polymorphisms and response to aspirin. Tang et al. [38]
explored whether aspirin and clopidogrel are affected by
competitive inhibition, with the assumption that if both
were agents were hydrolyzed by CES1, then prolonged
antithrombogenic activity would occur. However, the
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authors found that clopidogrel is primarily hydrolyzed
by CES1, whereas aspirin is hydrolyzed by CES2. The SNP
A139T was associated with a 40% maximal decrease in
CES2 functioning and, thus, decreased aspirin hydrolysis.
The results show that genetic polymorphisms of CES2 may
account for the variability in aspirin response. However,
owing to the limited number of small population-based
studies, it is difficult to assess the relation between these
genetic variants and aspirin therapy.
Irinotecan
Irinotecan is an antitumor agent used in the treatment of
unresectable and metastatic colorectal cancer as well as
other malignancies (i.e., lung and gastric cancer), in com
bination with 5-fluorouracil and oxaliplatin. Irinotecan
is a prodrug that is hydrolyzed by the CES2 enzymes to
produce its active and inactive metabolites, SN-38 (7-ethyl-
10-hydroxycamptothecin) and 7-ethyl-10-[4-N-(5-amino
pentanoic acid)-1-piperidino] carbonyloxycamptothecin,
respectively [58]. SN-38 is a DNA topoisomerase I inhibitor
and leads to cancer cell death [42]. The topoisomerase I
nuclear enzyme is involved in replication and is respon
sible for unwinding DNA and preventing single breaks.
SN-38 is highly cytotoxic and acts by destabilizing topo
isomerase I-DNA covalent complexes formed in cancer
cells [42]. It has been hypothesized that CES2 polymor
phisms may influence both pharmacokinetic and tumor
cell exposure to irinotecan by regulating drug availability,
retention, and efflux.
To date, no studies have assessed the effect of CES2
polymorphisms on the safety and efficacy of irinotecan.
However, it has been shown that that among Japanese
cancer patients, the missense variants of CES2 (rs72547531
and rs72547532) have been associated with low in vitro
expression and function of CES2, as well as reduced in vivo
CES2 activity in irinotecan-treated patients [39]. These
results suggest that genetic variants of CES2 may contrib
ute to the variability in irinotecan response; yet, more
research in larger populations is required.
Conclusions
CES1 and CES2 have recently emerged as important phar
macogenetic regulators of drug metabolism. Indeed, this
review has demonstrated that genetic polymorphisms of
CES1 and CES2 may influence the interindividual variation
of a diverse group of therapeutic agents, including dabi
gatran etexilate, MPH, oseltamivir, imidapril, clopidogrel,
150Merali etal.: The pharmacogenetics of carboxylesterases: CES1 and CES2
aspirin, and irinotecan. However, despite these promising
results, further research is needed to truly understand the
role of genetic polymorphisms, such as large-scale CES1
and CES2 pharmacogenetic studies to assess drug-gene
interactions in vivo. Ultimately, clearer evidence from
large outcome studies may provide more information on
the clinical usefulness of CES genotyping to better opti
mize drug therapy across a wide range of drug classes and
to reduce the risk of adverse events.
Conflict of interest statement
Authors conflict of interest disclosure: The authors
stated that there are no conflicts of interest regarding the
publication of this article.
Research funding: None declared.
Employment or leadership: None declared.
Honorarium: None declared.
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