Prognostic Analysis of Butylphthalide Therapy Guided by CYP2C19 Genotype in Patients with Acute Cerebral Infarction

Summary

This article describes a study evaluating the prognosis of CYP2C19 genotype-guided butylphthalide therapy in acute cerebral infarction, showing that poor metabolizers have worse outcomes, and that Hcy, NIHSS, and CYP2C19 are independent predictors.

Abstract

To investigate the prognosis of patients with acute-phase cerebral infarction treated with butylphthalide based on cytochrome P450 2C19 (CYP2C19) genotype. A total of 175 patients with acute cerebral infarction treated with butylphthalide at our hospital from January 2022 to January 2025 were retrospectively enrolled. Based on modified Rankin Scale (mRS) scores at 3 months post-treatment, patients were categorized into a good prognosis group (mRS ≤2) and a poor prognosis group (mRS ≥3). CYP2C19 genotypes and metabolic phenotypes were analyzed. Clinical data and genotype distributions were compared between groups, and logistic regression analysis was performed to identify prognostic factors. Intermediate metabolizers predominated (46.29%), while poor metabolizers were the least common (12.00%). Compared to the good prognosis group, the poor prognosis group exhibited a significantly higher prevalence of hypertension (P <0.05), elevated serum homocysteine (Hcy) levels (P <0.05), and higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (P <0.05). Poor metabolizers (CYP2C19*2/*2, *2/*3, *3/*3) were overrepresented in the poor prognosis group, whereas rapid metabolizers (CYP2C19*1/*1) were more frequent in the good prognosis group (P <0.05). Logistic regression analysis identified three independent predictors of poor prognosis after controlling for covariates: elevated homocysteine levels (odds ratio (OR) = 2.255; 95% CI: 1.404–3.622; P < 0.001), higher baseline NIHSS score (OR = 3.127; 95% CI: 1.508–6.482; P = 0.002), and CYP2C19 poor metabolizer status (OR = 4.559; 95% CI: 2.392–8.688; P < 0.001). Elevated Hcy levels, increased NIHSS scores, and CYP2C19 poor metabolizer phenotypes are significant prognostic factors in butylphthalide-treated acute cerebral infarction. Patients with poor metabolizer genotypes exhibit worse outcomes, highlighting the need for personalized treatment strategies to optimize outcomes.

Introduction

Acute cerebral infarction, accounting for over 80% of all stroke cases, represents a critical global health burden characterized by high mortality, disability, and recurrence rates. As the second leading cause of death worldwide, it imposes severe socioeconomic impacts through long-term neurological impairment and functional dependency¹. The urgency of therapeutic intervention is underscored by the concept of "time-is-brain" – where approximately 1.9 million neurons perish per minute during untreated ischemia².

In this clinical landscape, butylphthalide (dl-3-n-butylphthalide) ha....

Protocol

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of Huizhou Central People's Hospital (Approval No. 2022-015). This study was not registered as a clinical trial due to its retrospective design. Informed consent was waived due to the retrospective nature of the analysis, and all patient data were de-identified. The regents and the equipment used are listed in the Table of Materials.

1. Study design and patient selection

As a retrospective multicenter study, we acknowledge the potential for selection bias. T....

Results

Distribution of CYP2C19 genotypes and metabolic phenotypes

The analysis of CYP2C19 genotypes and metabolic phenotypes in 175 patients with acute cerebral infarction revealed that intermediate metabolizers were the most prevalent (81/175, 46.29%), while poor metabolizers were the least common (21/175, 12.00%). Genotype distribution showed that CYP2C19 * 1/*1 (rapid metabolizer) was the most frequent genotype (73/175, 41.71%), followed by *1/*2 (intermediate metabolizer, 72/175,.......

Discussion

Acute cerebral infarction, a syndrome caused by cerebrovascular insufficiency, represents a critical neurological emergency^8,9,10. Butylphthalide has emerged as a principal therapeutic agent for this condition. Studies have demonstrated that its therapeutic mechanisms involve suppression of intracellular free radical generation, enhancement of antioxidant enzyme activity, and preservation of mitochondrial integrity, collectively.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
2× TaqMan Master Mix	Thermo Fisher Scientific	4371355	Used for CYP2C19 genotyping real-time PCR reaction
Agarose	N/A	N/A	Used to prepare 2% gel for agarose gel electrophoresis
Butylphthalide capsules	NBP Pharmaceutical Co., Ltd.	H20050299	0.1 g per capsule; administered at 0.2 g three times daily on an empty stomach
DNA extraction kit	Tiangen Biotech	DP304	Used for genomic DNA extraction from serum samples; includes lysis buffer, wash buffer and elution buffer
Electronic case report forms (e-CRF)	N/A	N/A	Systematic clinical data collection tool covering five clinical data domains
ELISA kit for homocysteine (Hcy)	Shanghai Enzyme-linked Biotech	N/A	Detection range 5–50 μmol/L; coefficient of variation <5%; for serum Hcy measurement
Elution buffer	Tiangen Biotech	N/A	Pre-warmed to 70°C; component of DP304 DNA extraction kit, for DNA elution
Eppendorf 5425R Refrigerated High-Speed Centrifuge	Eppendorf	5425R	Used for serum isolation and genomic DNA purification centrifugation steps
Hi-SNP sequencing platform/analysis system	BGI Genomics	N/A	Second-generation sequencing; used for CYP2C19 genotype confirmation with 100× coverage
HpyCH4V restriction enzyme	New England Biolabs	N/A	Used for restriction fragment length polymorphism analysis of discordant genotyping results
Lysis buffer	Tiangen Biotech	N/A	Component of DP304 DNA extraction kit; incubated with samples at 56°C for 10 min
NanoDrop spectrophotometer	Thermo Fisher Scientific	N/A	Used to adjust final genomic DNA concentration to 50-100 ng/μL
Nuclease-free water	N/A	N/A	Used to prepare CYP2C19 genotyping real-time PCR reaction mixture
Primer-probe mix (CYP2C19*2)	Thermo Fisher Scientific	C__25986767_30	Specific for CYP2C19*2 genotyping in real-time PCR
Primer-probe mix (CYP2C19*3)	Thermo Fisher Scientific	C__27861809_10	Specific for CYP2C19*3 genotyping in real-time PCR
Roche LightCycler 480 II system	Roche Diagnostics	LightCycler 480 II	Real-time PCR system for CYP2C19 genotyping
Roche/Hitachi 7600 analyzer	Roche Diagnostics/Hitachi	7600	For lipid profile (TC, TG, LDL-C, HDL-C) measurement; assay ranges for lipids specified in the study
SPSS	IBM Corp.	25	Statistical analysis software; used for all study data analysis (χ² tests, t-tests, logistic regression, etc.)
Wash buffer	Tiangen Biotech	N/A	Component of DP304 DNA extraction kit; two wash steps with 500 μL each in DNA purification