It is well established that polymorphic genetic variations in some drug-metabolizing enzymes can dramatically affect the handling of certain drugs in the body, sometimes with severe consequences for toxicity and therapeutic efficacy [1]. More recently, polymorphisms in the active drug efflux transporter MDR1 P-glycoprotein have also been associated with changes in drug disposition, although the effects observed to date are fairly modest [2]. In this issue of the journal, Kerb et al. [3] potentially add a new twist to the cocktail of factors affecting drug disposition. In a Caucasian population, the authors found many polymorphisms in the human polyspecific organic cation transporter 1 (hOCT1) gene SLC22A1, some of which result in amino acid substitutions that severely reduce and alter substrate transport in in-vitro assays. The question that immediately emerges is what pharmacological parameters will be affected in vivo by such altered OCT1 function?