This is supporting information for the peer reviewed version of the following article: Amstutz, Ursula & H.

Shear,
Neil & Rieder, Michael & Hwang, Soomi & Fung, Vincent & Nakamura, Hidefumi & B. Connolly, Mary & Ito,
Shinya & C. Carleton, Bruce. (2014). Recommendations for HLA-B*15:02 and HLA-A*31:01 genetic testing to
reduce the risk of carbamazepine-induced hypersensitivity reactions. Epilepsia. 55, which has been published in final
form at 10.1111/epi.12564. This information may be used for non-commercial purposes in accordance with Wiley
Terms and Conditions for Self-Archiving.

Recommendations for HLA-B*15:02 and HLA-A*31:01 genetic testing to reduce the risk of
carbamazepine-induced hypersensitivity reactions

SUPPORTING INFORMATION

1. Glossary
The following definitions and abbreviations are used throughout the document:
CBZ: Carbamazepine
HSR: Hypersensitivity reaction
Carrier: An individual who carries a particular HLA gene variant either in the heterozygous (one
copy of the variant allele) or in the homozygous (two copies of the variant allele) state
SJS/TEN: Stevens-Johnson syndrome and toxic epidermal necrolysis disease spectrum
HLA: Human Leukocyte Antigen
HSS: Hypersensitivity syndrome, also known as drug reaction with eosinophilia and systemic
symptoms (DRESS) or drug-induced hypersensitivity syndrome (DIHS)
MPE: Maculopapular exanthema; used here to describe various milder CBZ-induced cutaneous
reactions, broadly defined as a CBZ-induced rash that occurred within the first 3 months of
CBZ treatment and resulted in discontinuation of the drug
OXC: Oxcarbazepine
PPV: Positive predictive value; the proportion of those patients who carry the genetic risk variant,
who develop a HSR (i.e. the proportion of true positives among all patients with a positive
test result). For example, a PPV of 40% means that out of 100 patients who have the
genetic risk variant, 40 would develop a HSR. The PPV as used here is dependent on the
overall frequency of the HSR and is calculated as:
f cases × f HSR
( f cases × f HSR ) + ( f tolerant × (1 − f HSR ))

fHSR = frequency of the HSR among new users of CBZ

fcases = frequency€ of the risk variant among patients with the HSR (sensitivity)
ftolerant = frequency of the risk variant among patients who tolerate CBZ (1 – specificity)
Sensitivity: The proportion of those patients who develop a HSR, who carry the genetic risk
variant (i.e. the frequency of the risk variant among patients who develop a HSR). For
example, a sensitivity of 80% means that out of 100 patients with a CBZ-induced HSR, 80

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 carry the genetic risk variant. The sensitivity provides information about how many of all
the patients who develop a CBZ-induced HSR can be identified with the genetic test.
Specificity: The proportion of those patients who tolerate CBZ, who do not carry the risk variant.
For example, a specificity of 99% means that out of 100 patients who tolerate CBZ, 99 do
not have the risk variant. The specificity provides information about how many of all
patients who tolerate CBZ can be identified with a negative test result.

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2. Supplementary Tables

Supplementary Table S1: HLA-B*15:02 and SJS/TEN

Population HLA- % positive for HLA-B*15:02 Total number of patients
B*15:02 SJS/TEN cases CBZ- Population SJS/TEN CBZ- Population
common tolerant cases tolerant
(>1%
frequency)
Chinese YES 97 (72-100)1-9 4-151-6,8,9 9-182-4,6 144 523 504
Thai YES 92 (88-100)10-13 10-19%10- - 61a 130a -
13
14-16
Indian YES 93 (75-100) - - 29 - -
Malaysian YES 80 (75-100)15,17 - 1615 20 - 300
Korean NO 1418 018 0.418 7 50 485
19-21 22 b
Japanese NO 0 0.3 18 371
European NO 023-25 024,25 0.223 14 108 1290
Caribbean unknown 025 2
Individual SJS/TEN cases positive for HLA-B*15:02 reported: Vietnam, Cambodia, Reunion Island, Sri
Lanka23,25
a
Overlap between patients included in studies10,11,13
b
One study reported absence of HLA-B*15:02 carriers among all CBZ-SJS/TEN cases without providing
number of cases
Bold indicates a significant association with SJS/TEN

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Supplementary Table S2: Population frequencies of HLA-B*15:02. For populations that are not listed in
the table, no data was available from published studies in The Allele Frequency Net Database
(www.allelefrequencies.net).
Positive for HLA-B*15:02 Populations (countries/regions/ethnic groups studied)
(% of population)
<0.1 Caucasian: Bulgaria, Germany, Northern Ireland, Italy, New South
Wales
Latin American: Hispanic (USA)
African: Morocco, Burkina Faso, Zulu (South Africa)
Asian: China (Tibet), Oman
0.1-1 African: African American (USA)
Latin American: Mexican Mestizo (USA)
Asian: Japan, Korea
Native American: Alaska Yupik
1-5 Asian: China (North Han, Inner Mongolia Region), India (Dehli,
Mumbai Maratha, North)
>5 Asian: China (South Han, Canton Han, Yunnan Province, Guizhou
Province, Singapore Chinese, Southwest Dai, Guangxi Region,
Guangzhou, Guangdong Province Meizhou Han), Taiwan, Malaysia,
Vietnam, Philippinesa, India (Khandesh Region Pawra, West Bhil),
Indonesia
a
unpublished data

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Supplementary Table S3: HLA-A*31:01 and HSS/MPE
Popu- % carriers of HLA-A*31:01 Total number of patients
lation MPEa HSS All HSR CBZ- Popu- MPE HSS All CBZ- Popu-
cases cases cases tolerant lation cases cases HSR tolerant lation
cases
Japanese 47 5820 5820; 5022 1320 14- 1026;
36 7720; 420 864
(2026; 1522,26 3520 2222
20
54 )
Chinese 331 15b,1 - 31 - 18 13 - 144 -
18
Korean - 59 - 1418 1018 - 17 - 50 485
European 2227 3727 2627 427 527 106 27 145 257 2691
c 25 25 25 25
Mixed 23 50 21 3 - 26 6 42 91 -
a
includes various milder CBZ-induced HSRs: rash without systemic symptoms, maculopapular eruption,
erythema multiforme, erythema, erythroderma, fixed drug eruption, and unclassified drug rashes
b
no statistically significant difference in carrier frequency compared to CBZ-tolerant patients.
c
Canadian children of mostly European ancestry, but also including various other origins
Bold indicates a significant association with MPE, HSS or all HSRs, respectively

Supplementary Table S4: HLA-A*31:01 and SJS/TEN

Population % carriers of HLA-A*31:01 Total number of patients
SJS/TEN cases CBZ-tolerant Population SJS/TEN cases CBZ-tolerant Population
Japanese 55 1320 14-1522,26 11 (526; 620) 420 864
(2026; 8320)
Chinesea 2a, 1,9 21,9 92 176
b, 18
Korean 43 1418 1018 7 50 485
European 4227 427 527 12 257 2691
Mixedc 0b, 25 325 - 9 91
a
confounded by a large number of patients carrying HLA-B*15:02; frequency excluding HLA-B*15:02
positive patients: 33% (6 patients, 2 positive for HLA-A*31:01)
b
no statistically significant difference in carrier frequency compared to CBZ-tolerant patients.
c
including 6 children originating from populations where HLA-A*31:01 is common (4 European, 1
Canada First Nations, 1 Sri Lanka )
Bold indicates a significant association with SJS/TEN

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Supplementary Table S5: Population frequencies of HLA-A*31:01. For populations that are not listed in
the table, no data was available from www.allelefrequencies.net.
Positive for HLA- Populations (countries/regions/ethnic groups studied)
A*31:01
(% of population)
<3 African: Cameroon, Kenya, Rwanda, Senegal, Zulu (South Africa), USA African
American
Asian: China (Southwest Dai, Guizhou Province, Qinghai Province, Yunnan
Province Jinuo, Yunnan Province Lisu, Yunnan Province Wa, Yunnan Province
Bulang), India (West Bhil), Malay (Singapore Riau)
3-5 Caucasian: Germany, Bulgaria, Northern Ireland, Poland, Scotland Orkney, USA
Caucasian
Asian: Thailand, Vietnam, Singapore Chinese, India (North, West Coast Parsi),
Iran, Jordan, Oman
African: Morocco, Tunisia, Uganda Kampala, Zambia Lusaka
5-10 Hispanic: Spain, Portugal, USA Hispanic
Asian: China (Yunnan Province Han, Yunnan Province Nu, Canton Han,
Beijing, South Han), India (New Dehli, Mumbai Maratha), Pakistana, Papua
New Guineaa, USA Asian
>10 Native American: Argentina Gran Chaco, Mexico Oaxaca, Mexico Sonora Seri,
South Dakota Lakota Sioux, New Mexico Navajo, Arizona Pima Titikaka Lake
Uro, Brazil Terena, Hawaii Okinawa
Asian: Japan, Korea, China (Tibet, Inner Mongolian Region, North Han), India
(Tamil Nadu Nadar, Andhra Pradesh Golla, Khandesh Region Pawra), Tuva,
Mongolia Buryat
Caucasian: Finland, Sami
a
lower frequencies in some subpopulations

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3. Supplementary Methods
3.1. Systematic Literature Search
A comprehensive systematic search of the relevant English-language, published, peer-reviewed
literature was performed to identify available evidence on genetic testing for HLA-B*15:02 and
HLA-A*31:01 in the context of carbamazepine therapy. Embase from the period of 1980 to July
2011 (using the OVID interface) and MEDLINE from the period of 1948 to June 2011 (using the
OVID interface) were searched. Titles and abstracts of all records retrieved were scanned for
relevance to the guideline key questions. English language original studies relevant to the
guideline questions were selected for full-text review. Editorials, notes, short surveys, and review
articles were not included in the full-text review. Conference abstracts were only included if they
were published in or after 2009. Following the initial literature search in July 2011, monthly
updates of the systematic literature search were performed. The last update of the literature search
for the development of clinical practice recommendations was performed in February 2012. An
additional literature search was performed as part of the revision of this manuscript in November
2013 to include most recent studies.
Systematic literature search strategy
Database: Embase <1980 to Present>, Ovid MEDLINE(R) 1948 to Present with Daily Update
1. (carbamazepine or tegretol).mp. [mp=ti, ab, sh, hw, tn, ot, dm, mf, dv, kw, ps, rs, nm, an, ui]
(60049)
2. (pharmacogen* or genetic* or genom* or gene varia* or genotype* or polymorphism*).mp.
(3373747)
3. hla*.mp. (211429)
4. (adverse or cutaneous or epiderm* or skin or steven* or toxic or hypersensitivity or
reaction*).mp. (4845719)
5. 1 and 2 and 3 and 4 (337)
6. remove duplicates from 5 (249)
7. limit 6 to (editorial or letter or note or "review" or short survey or comment) (119)
8. 6 not 7 (130)
9. limit 8 to english language (121)
Number of articles screened: 121
Total number of articles reviewed: 33
Removed:
• Irrelevant articles (articles that did not study the correlation between genotypes and CBZ-
induced adverse drug reactions)
• Non-original studies, including editorials, notes, short surveys and reviews
• Conference abstracts prior to 2009

Data on worldwide population frequencies of HLA-B*15:02, HLA-A*31:01 and HLA-B*15:11

were obtained from The Allele Frequency Net Database (www.allelefrequencies.net), a public
database which contains frequency information of various immune genes, including the HLA
genes.28 Only data published in the literature was included in the presented summary tables, with
the exception of one population estimate of the HLA-B*15:02 carrier frequency from the
Philippines. This estimate was included because it was the only estimate available for this
population, indicates a high frequency of the risk allele in this population, and was therefore
considered of high clinical importance.

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3.2. Critical appraisal of evidence
Strength of scientific evidence was graded using an approach based on the scheme suggested by
the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working
group29 (Table 1) and similar to the grading scheme used by the Clinical Pharmacogenetics
Implementation Consortium (CPIC).30 This scheme was designed to evaluate the quality and
strength of a body of evidence for a given outcome across studies based on the consistency of
results, magnitude of the effect, as well as the number and quality of studies conducted. Study
quality assessment included the evaluation of limitations in the study design and data quality,
imprecision of effect estimates and statistical power, and indirectness of evidence, as well as the
possibility of publication bias. Due to the rarity of severe CBZ HSRs, randomized controlled
trials, usually considered the highest quality or level of evidence for clinical practice guideline
development, are not feasible, and the majority of studies retrieved were expected to be
retrospective case-control studies. The GRADE evidence grading scheme was thus modified,
giving less weight to the type of study (randomized controlled trials vs observational studies).

3.3. Development of clinical practice recommendations

Clinicians, scientists and clinician scientists were chosen and invited to participate in the CPNDS
clinical recommendation group based on their interest and expertise in the following areas:
pharmacogenomics, clinical pharmacology, medical genetics, internal medicine, dermatology,
neurology, pediatrics, and other specialists with expertise relevant to other pharmacogenetic
markers evaluated by the same working group. Clinical practice recommendations were
developed during a two-day workshop using an informal consensus process. All CPNDS clinical
recommendation group members participated in the workshop, with the exception of external
reviewers (see below secton 3.4.). Supporting evidence and draft recommendations as a starting
point for discussion were presented by one member to the group, followed by discussion and
revision of recommendations according to group consensus.
Each clinical practice recommendation was assigned one of three levels of strength, based on the
strength of available evidence, on which the recommendation was formulated, the balance
between benefits and risks of genetic testing and genotype-guided treatment, as well as the
likelihood of variability in the individual values and preferences of patients (Table 2). A strong
recommendation (level A) is considered a recommended therapeutic option that is expected to be
chosen by a majority of informed health care providers and patients, whereas a moderate level
(B) is given for a recommendation that is expected to require individualized informed decision
making by patients and health care providers, taking into account the individual needs, values and
preferences of each patient. A recommendation of level C is considered an optional
recommendation, e.g. for use of a genetic test in a research context.

3.4. Review
In a first step, the draft document was reviewed internally by all development group members.
Secondly, the draft was reviewed externally by four content experts who had not been involved in
the recommendation development process and did not participate in the recommendation
development workshop. Due to their contribution to this document as part of this review process,
these external experts were included as members of the CPNDS clinical recommendation group
after their review of the evidence synthesis and clinical practice recommendations. Finally, a
third review was performed by a group of members of the target audience of this guidance

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document. The aim of this third review step was to ensure the clarity of the presented evidence
review and recommendations, as well as their ease of use and applicability in clinical practice.

4. Test Availability
The availability of diagnostic genetic tests varies locally and was not exhaustively assessed in a
systematic search. For enquiries regarding local availability and cost of genetic tests, local
diagnostic laboratories (e.g. hospital-based molecular diagnostic or immunogenetics laboratories)
should be contacted. Furthermore, the following commercial laboratories provide genetic testing
services in North America (non-exhaustive list):

- Quest laboratories: www.questdiagnostics.com

- Laboratory Corporation of America (Labcorp): www.labcorp.com
- Gammy-Dynacare Diagnostic Laboratories: www.gamma-dynacare.com

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