Drug Interactions Results
Drug interactions for the following 27 drug(s):
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clonidine
diphenhydramine
doxycycline
lorazepam
metoclopramide
metoprolol
omeprazole
tramadol
trazodone
Ambien (zolpidem)
Aranesp (darbepoetin alfa)
Bactrim DS (sulfamethoxazole/trimethoprim)
Celexa (citalopram)
Combivent (albuterol/ipratropium)
Dialyvite (multivitamin with iron)
Flexeril (cyclobenzaprine)
Humalog (insulin lispro)
Lantus (insulin glargine)
Lexapro (escitalopram)
Lortab 7.5/500 (acetaminophen/hydrocodone)
Lyrica (pregabalin)
PhosLo Gelcap (calcium acetate)
Roxanol (morphine)
Senokot (senna)
Symbicort (budesonide/formoterol)
Venofer (iron sucrose)
Zofran (ondansetron)
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Interactions between your selected drugs
morphine ↔ tramadol
Applies to: Roxanol (morphine), tramadol
GENERALLY AVOID: Concomitant use of tramadol increases the seizure risk in patients taking other opioids. These agents are often individually epileptogenic and may have additive effects on seizure threshold during coadministration. CNS- and respiratory-depressant effects may also be additive. In patients who have been previously dependent on or chronically using opioids, tramadol can also reinitiate physical dependence or precipitate withdrawal symptoms.MANAGEMENT: Concomitant use of tramadol and other opioids should be avoided in general. Tramadol should not be used in opioid-dependent patients, and use in patients who are chronically on opioids is also not recommended. Tramadol is contraindicated in patients with acute opioid intoxication. Tramadol dosage should be reduced if it must be used in patients receiving opioids. Patients should be monitored for development of seizures and CNS and respiratory depression.
hydrocodone ↔ tramadol
Applies to: Lortab 7.5/500 (acetaminophen/hydrocodone), tramadol
GENERALLY AVOID: Concomitant use of tramadol increases the seizure risk in patients taking other opioids. These agents are often individually epileptogenic and may have additive effects on seizure threshold during coadministration. CNS- and respiratory-depressant effects may also be additive. In patients who have been previously dependent on or chronically using opioids, tramadol can also reinitiate physical dependence or precipitate withdrawal symptoms.MANAGEMENT: Concomitant use of tramadol and other opioids should be avoided in general. Tramadol should not be used in opioid-dependent patients, and use in patients who are chronically on opioids is also not recommended. Tramadol is contraindicated in patients with acute opioid intoxication. Tramadol dosage should be reduced if it must be used in patients receiving opioids. Patients should be monitored for development of seizures and CNS and respiratory depression.
metoclopramide ↔ tramadol
Applies to: metoclopramide, tramadol
MONITOR CLOSELY: The risk of seizures may be increased during coadministration of tramadol with any substance that can reduce the seizure threshold, such as selective serotonin reuptake inhibitors (SSRI antidepressants or anorectics), monoamine oxidase inhibitors, neuroleptic agents, central nervous system stimulants, opioids, tricyclic antidepressants, other tricyclic compounds (e.g., cyclobenzaprine, phenothiazines), carbapenems, cholinergic agents, fluoroquinolones, interferons, chloroquine, mefloquine, lindane, and theophylline. These agents are often individually epileptogenic and may have additive effects when combined. Many of these agents also exhibit CNS- and/or respiratory-depressant effects, which may be enhanced during their concomitant use with tramadol.MANAGEMENT: Caution is advised if tramadol is administered with any substance that can reduce the seizure threshold, particularly in the elderly and in patients with epilepsy, a history of seizures, or other risk factors for seizures (e.g., head trauma, brain tumor, metabolic disorders, alcohol and drug withdrawal, CNS infections).
cyclobenzaprine ↔ tramadol
Applies to: Flexeril (cyclobenzaprine), tramadol
MONITOR CLOSELY: The risk of seizures may be increased during coadministration of tramadol with any substance that can reduce the seizure threshold, such as selective serotonin reuptake inhibitors (SSRI antidepressants or anorectics), monoamine oxidase inhibitors, neuroleptic agents, central nervous system stimulants, opioids, tricyclic antidepressants, other tricyclic compounds (e.g., cyclobenzaprine, phenothiazines), carbapenems, cholinergic agents, fluoroquinolones, interferons, chloroquine, mefloquine, lindane, and theophylline. These agents are often individually epileptogenic and may have additive effects when combined. Many of these agents also exhibit CNS- and/or respiratory-depressant effects, which may be enhanced during their concomitant use with tramadol.MANAGEMENT: Caution is advised if tramadol is administered with any substance that can reduce the seizure threshold, particularly in the elderly and in patients with epilepsy, a history of seizures, or other risk factors for seizures (e.g., head trauma, brain tumor, metabolic disorders, alcohol and drug withdrawal, CNS infections).
trazodone ↔ citalopram
Applies to: trazodone, Celexa (citalopram)
MONITOR CLOSELY: Concomitant use of agents with serotonergic activity such as serotonin reuptake inhibitors, monoamine oxidase inhibitors, tricyclic antidepressants, 5-HT1 receptor agonists, ergot alkaloids, lithium, St. John's wort, phenylpiperidine opioids, dextromethorphan, and tryptophan may potentiate the risk of serotonin syndrome, which is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5-HT1A and 2A receptors. Symptoms of the serotonin syndrome may include mental status changes such as irritability, altered consciousness, confusion, hallucinations, and coma; autonomic dysfunction such as tachycardia, hyperthermia, diaphoresis, shivering, blood pressure lability, and mydriasis; neuromuscular abnormalities such as hyperreflexia, myoclonus, tremor, rigidity, and ataxia; and gastrointestinal symptoms such as abdominal cramping, nausea, vomiting, and diarrhea.MANAGEMENT: In general, the concomitant use of multiple serotonergic agents should be avoided if possible, or otherwise approached with caution if potential benefit is deemed to outweigh the risk. Patients should be closely monitored for symptoms of the serotonin syndrome during treatment. Particular caution is advised when increasing the dosages of these agents. The potential risk for serotonin syndrome should be considered even when administering serotonergic agents sequentially, as some agents may demonstrate a prolonged elimination half-life. For example, a 5-week washout period is recommended following use of fluoxetine before administering another serotonergic agent. If serotonin syndrome develops or is suspected during the course of therapy, all serotonergic agents should be discontinued immediately and supportive care rendered as necessary. Moderately ill patients may also benefit from the administration of a serotonin antagonist (e.g., cyproheptadine, chlorpromazine). Severe cases should be managed under consultation with a toxicologist and may require sedation, neuromuscular paralysis, intubation, and mechanical ventilation in addition to the other measures.
trazodone ↔ escitalopram
Applies to: trazodone, Lexapro (escitalopram)
MONITOR CLOSELY: Concomitant use of agents with serotonergic activity such as serotonin reuptake inhibitors, monoamine oxidase inhibitors, tricyclic antidepressants, 5-HT1 receptor agonists, ergot alkaloids, lithium, St. John's wort, phenylpiperidine opioids, dextromethorphan, and tryptophan may potentiate the risk of serotonin syndrome, which is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5-HT1A and 2A receptors. Symptoms of the serotonin syndrome may include mental status changes such as irritability, altered consciousness, confusion, hallucinations, and coma; autonomic dysfunction such as tachycardia, hyperthermia, diaphoresis, shivering, blood pressure lability, and mydriasis; neuromuscular abnormalities such as hyperreflexia, myoclonus, tremor, rigidity, and ataxia; and gastrointestinal symptoms such as abdominal cramping, nausea, vomiting, and diarrhea.MANAGEMENT: In general, the concomitant use of multiple serotonergic agents should be avoided if possible, or otherwise approached with caution if potential benefit is deemed to outweigh the risk. Patients should be closely monitored for symptoms of the serotonin syndrome during treatment. Particular caution is advised when increasing the dosages of these agents. The potential risk for serotonin syndrome should be considered even when administering serotonergic agents sequentially, as some agents may demonstrate a prolonged elimination half-life. For example, a 5-week washout period is recommended following use of fluoxetine before administering another serotonergic agent. If serotonin syndrome develops or is suspected during the course of therapy, all serotonergic agents should be discontinued immediately and supportive care rendered as necessary. Moderately ill patients may also benefit from the administration of a serotonin antagonist (e.g., cyproheptadine, chlorpromazine). Severe cases should be managed under consultation with a toxicologist and may require sedation, neuromuscular paralysis, intubation, and mechanical ventilation in addition to the other measures.
tramadol ↔ citalopram
Applies to: tramadol, Celexa (citalopram)
GENERALLY AVOID: The coadministration of selective serotonin reuptake inhibitors (SSRIs) with tramadol, which has weak serotonin reuptake inhibiting effect, may potentiate the risk of serotonin syndrome, which is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5HT1A receptors. Patients receiving this combination may also have an increased risk of seizures. Pharmacokinetically, coadministration with certain SSRIs, namely fluoxetine, paroxetine and possibly sertraline, may result in decreased plasma concentrations of the active O-demethylated (M1) metabolite of tramadol due to inhibition of CYP450 2D6, the isoenyzme responsible for the formation of the metabolite. The clinical significance of this potential interaction is unknown. However, M1 is thought to possess up to 6 times the analgesic effect of tramadol, thus diminished therapeutic response to tramadol should be considered.MANAGEMENT: In general, the concomitant use of SSRIs and tramadol should be avoided if possible, or otherwise approached with caution if potential benefit is deemed to outweigh the risk. Patients treated with the combination should be closely monitored for signs and symptoms of excessive serotonergic activity such as CNS irritability, altered consciousness, confusion, myoclonus, ataxia, abdominal cramping, hyperpyrexia, shivering, pupillary dilation, diaphoresis, hypertension, and tachycardia.
tramadol ↔ escitalopram
Applies to: tramadol, Lexapro (escitalopram)
GENERALLY AVOID: The coadministration of selective serotonin reuptake inhibitors (SSRIs) with tramadol, which has weak serotonin reuptake inhibiting effect, may potentiate the risk of serotonin syndrome, which is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5HT1A receptors. Patients receiving this combination may also have an increased risk of seizures. Pharmacokinetically, coadministration with certain SSRIs, namely fluoxetine, paroxetine and possibly sertraline, may result in decreased plasma concentrations of the active O-demethylated (M1) metabolite of tramadol due to inhibition of CYP450 2D6, the isoenyzme responsible for the formation of the metabolite. The clinical significance of this potential interaction is unknown. However, M1 is thought to possess up to 6 times the analgesic effect of tramadol, thus diminished therapeutic response to tramadol should be considered.MANAGEMENT: In general, the concomitant use of SSRIs and tramadol should be avoided if possible, or otherwise approached with caution if potential benefit is deemed to outweigh the risk. Patients treated with the combination should be closely monitored for signs and symptoms of excessive serotonergic activity such as CNS irritability, altered consciousness, confusion, myoclonus, ataxia, abdominal cramping, hyperpyrexia, shivering, pupillary dilation, diaphoresis, hypertension, and tachycardia.
trazodone ↔ tramadol
Applies to: trazodone, tramadol
GENERALLY AVOID: Due to its serotonergic activity, coadministration of tramadol with serotonin-enhancing drugs such as SSRIs, SNRIs, nefazodone, trazodone, and mirtazapine may potentiate the risk of serotonin syndrome, which is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5-HT1A and 2A receptors. Symptoms of the serotonin syndrome may include mental status changes such as irritability, altered consciousness, confusion, hallucinations, and coma; autonomic dysfunction such as tachycardia, hyperthermia, diaphoresis, shivering, blood pressure lability, and mydriasis; neuromuscular abnormalities such as hyperreflexia, myoclonus, tremor, rigidity, and ataxia; and gastrointestinal symptoms such as abdominal cramping, nausea, vomiting, and diarrhea. Patients receiving tramadol with serotonin-enhancing drugs may also have an increased risk of seizures due to additive epileptogenic effects of these agents.MANAGEMENT: In general, the use of tramadol in combination with highly serotonergic agents should be avoided if possible, or otherwise approached with caution if potential benefit is deemed to outweigh the risk. Patients should be closely monitored for symptoms of the serotonin syndrome during treatment. Particular caution is advised when increasing the dosages of these agents. The potential risk for serotonin syndrome should be considered even when administering serotonergic agents sequentially, as some agents may demonstrate a prolonged elimination half-life.
clonidine ↔ metoprolol
Applies to: clonidine, metoprolol
MONITOR: Clonidine and beta-blockers may have synergistic pharmacodynamic effects resulting in marked AV block, bradycardia, and hypotension. Conversely, cases of antagonism of hypotensive effects have been reported, the mechanism of which is unknown. In addition, potentiation of the hypertensive rebound associated with abrupt withdrawal of clonidine or both clonidine and the beta blocker may occur. Increased blood pressure, hypertensive crisis, hypertensive encephalopathy, strokes, and fatalities have been reported after clonidine withdrawal. The proposed mechanism is related to increased catecholamine release after clonidine withdrawal, and concurrent beta-blockade results in unopposed alpha-adrenergic effects of the catecholamines, resulting in vasoconstriction. Patients who discontinue clonidine while taking noncardioselective beta blockers appear to be at a higher risk of developing rebound hypertension.MANAGEMENT: Close monitoring of blood pressure is recommended for patients receiving this combination. Patients should be advised to notify their doctor if they experience a reduced heart rate, dizziness, fainting, or headaches. Clonidine should never be discontinued abruptly, but should be tapered off over 2 to 4 days. The beta blocker should be discontinued a few days before gradually discontinuing the clonidine. It has also been suggested that replacing clonidine and the beta blocker with labetalol (an alpha and beta blocker) may prevent rebound hypertension although some symptoms from increased catecholamine levels occur, or selecting a cardioselective beta blocker (e.g. atenolol, betaxolol, bisoprolol, metoprolol) which is theoretically not expected to exacerbate the pressor response. Patients being withdrawn from clonidine should be carefully monitored for blood pressure changes, severe headache, tremors, apprehension, flushing, nausea, and vomiting.
metoprolol ↔ insulin lispro
Applies to: metoprolol, Humalog (insulin lispro)
MONITOR: Beta-blockers may inhibit some of the normal physiologic response to hypoglycemia. Symptoms of hypoglycemia such as tremors and tachycardia may be absent, making it more difficult for patients to recognize an oncoming episode. In addition, multiple effects on glucose metabolism have been reported, usually with the noncardioselective beta-blockers (e.g., propranolol, pindolol, timolol) but occasionally also with relatively beta-1 selective agents (e.g., metoprolol). Specifically, inhibition of catecholamine-mediated glycogenolysis and glucose mobilization in association with beta-blockade can potentiate insulin-induced hypoglycemia in diabetics and delay the recovery of normal blood glucose levels. Prolonged and severe hypoglycemia may occur, although these events have rarely been reported. Significant increases in blood pressure and bradycardia can also occur during hypoglycemia in diabetics treated with insulin and beta-blockers due to antagonism of epinephrine's effect on beta-2 adrenergic receptors, which leads to unopposed alpha-adrenergic effects including vasoconstriction. Other effects reported with various beta-blockers include decreased glucose tolerance and decreased glucose-induced insulin secretion.MANAGEMENT: In general, cardioselective beta-blockers are considered safer than noncardioselective agents in the treatment of diabetic patients. Nevertheless, caution is advised if they are prescribed to patients treated with insulin or oral antidiabetic agents that can cause hypoglycemia (e.g., insulin secretagogues), as cardioselectivity is not absolute and larger doses of beta-1 selective agents may pose some of the same risks as nonselective agents. Patients should be instructed about the need for regular monitoring of blood glucose levels and be aware that certain symptoms of hypoglycemia such as tremors and tachycardia may be masked. However, other symptoms such as headache, dizziness, drowsiness, nausea, hunger, and sweating may be unaffected. The same precautions are applicable in diabetic patients treated with ophthalmic beta-blockers.
metoprolol ↔ insulin glargine
Applies to: metoprolol, Lantus (insulin glargine)
MONITOR: Beta-blockers may inhibit some of the normal physiologic response to hypoglycemia. Symptoms of hypoglycemia such as tremors and tachycardia may be absent, making it more difficult for patients to recognize an oncoming episode. In addition, multiple effects on glucose metabolism have been reported, usually with the noncardioselective beta-blockers (e.g., propranolol, pindolol, timolol) but occasionally also with relatively beta-1 selective agents (e.g., metoprolol). Specifically, inhibition of catecholamine-mediated glycogenolysis and glucose mobilization in association with beta-blockade can potentiate insulin-induced hypoglycemia in diabetics and delay the recovery of normal blood glucose levels. Prolonged and severe hypoglycemia may occur, although these events have rarely been reported. Significant increases in blood pressure and bradycardia can also occur during hypoglycemia in diabetics treated with insulin and beta-blockers due to antagonism of epinephrine's effect on beta-2 adrenergic receptors, which leads to unopposed alpha-adrenergic effects including vasoconstriction. Other effects reported with various beta-blockers include decreased glucose tolerance and decreased glucose-induced insulin secretion.MANAGEMENT: In general, cardioselective beta-blockers are considered safer than noncardioselective agents in the treatment of diabetic patients. Nevertheless, caution is advised if they are prescribed to patients treated with insulin or oral antidiabetic agents that can cause hypoglycemia (e.g., insulin secretagogues), as cardioselectivity is not absolute and larger doses of beta-1 selective agents may pose some of the same risks as nonselective agents. Patients should be instructed about the need for regular monitoring of blood glucose levels and be aware that certain symptoms of hypoglycemia such as tremors and tachycardia may be masked. However, other symptoms such as headache, dizziness, drowsiness, nausea, hunger, and sweating may be unaffected. The same precautions are applicable in diabetic patients treated with ophthalmic beta-blockers.
clonidine ↔ insulin lispro
Applies to: clonidine, Humalog (insulin lispro)
MONITOR: Clonidine may diminish the physiological response to hypoglycemia induced by insulin and/or oral hypoglycemic agents (i.e., insulin secretagogues such as sulfonylureas and meglitinides). Clonidine inhibits the release of catecholamines, which are responsible for recovery of normal blood glucose levels and symptoms of hypoglycemia such as tremor, sweating, tachycardia, and blood pressure changes. In normal and hypertensive individuals, response to insulin-induced hypoglycemia has been shown to decrease significantly during administration of clonidine 0.45 to 0.9 mg daily. However, clonidine has also been reported to elevate plasma blood glucose and cause hyperglycemia.MANAGEMENT: Patients should be instructed about the need for regular monitoring of blood glucose levels and be aware that certain symptoms of hypoglycemia such as tremors, sweating, and tachycardia may be reduced or absent during treatment with clonidine.
clonidine ↔ insulin glargine
Applies to: clonidine, Lantus (insulin glargine)
MONITOR: Clonidine may diminish the physiological response to hypoglycemia induced by insulin and/or oral hypoglycemic agents (i.e., insulin secretagogues such as sulfonylureas and meglitinides). Clonidine inhibits the release of catecholamines, which are responsible for recovery of normal blood glucose levels and symptoms of hypoglycemia such as tremor, sweating, tachycardia, and blood pressure changes. In normal and hypertensive individuals, response to insulin-induced hypoglycemia has been shown to decrease significantly during administration of clonidine 0.45 to 0.9 mg daily. However, clonidine has also been reported to elevate plasma blood glucose and cause hyperglycemia.MANAGEMENT: Patients should be instructed about the need for regular monitoring of blood glucose levels and be aware that certain symptoms of hypoglycemia such as tremors, sweating, and tachycardia may be reduced or absent during treatment with clonidine.
doxycycline ↔ multivitamin with iron
Applies to: doxycycline, Dialyvite (multivitamin with iron)
GENERALLY AVOID: The bioavailability of oral tetracyclines and iron salts may be significantly decreased during concurrent administration. Therapeutic failure may result. The proposed mechanism is chelation of tetracyclines by the iron cation, forming an insoluble complex that is poorly absorbed from the gastrointestinal tract. In ten healthy volunteers, simultaneous oral administration of ferrous sulfate 200 mg and single doses of various tetracyclines (200 mg to 500 mg) resulted in reductions in the serum levels of methacycline and doxycycline by 80% to 90%, oxytetracycline by 50% to 60%, and tetracycline by 40% to 50%. In another study, 300 mg of ferrous sulfate reduced the absorption of tetracycline by 81% and that of minocycline by 77%. Conversely, the absorption of iron has been shown to be decreased by up to 78% in healthy subjects and up to 65% in patients with iron depletion when ferrous sulfate 250 mg was administered with tetracycline 500 mg. Available data suggest that administration of iron 3 hours before or 2 hours after a tetracycline largely prevents the interaction with most tetracyclines except doxycycline. Due to extensive enterohepatic cycling, iron binding may occur with doxycycline even when it is given parenterally. It has also been shown that when iron is administered up to 11 hours after doxycycline, serum concentrations of doxycycline may still be reduced by 20% to 45%.MANAGEMENT: Coadministration of a tetracycline with any iron-containing product should be avoided if possible. Otherwise, patients should be advised to stagger the times of administration by at least three hours, although separating the doses may not prevent the interaction with doxycycline.
doxycycline ↔ calcium acetate
Applies to: doxycycline, PhosLo Gelcap (calcium acetate)
ADJUST DOSING INTERVAL: Administration of a tetracycline with aluminum, calcium, or magnesium salts significantly decreases tetracycline serum concentrations. The proposed mechanism is chelation of tetracycline by the cation, forming an insoluble complex that is poorly absorbed from the gastrointestinal tract. The interaction has also been reported with parenteral doxycycline and oral antacids.MANAGEMENT: The administration of tetracyclines and preparations containing aluminum, magnesium, or calcium should be separated by two to three hours.
clonidine ↔ metoclopramide
Applies to: clonidine, metoclopramide
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
lorazepam ↔ metoclopramide
Applies to: lorazepam, metoclopramide
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
lorazepam ↔ morphine
Applies to: lorazepam, Roxanol (morphine)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
diphenhydramine ↔ morphine
Applies to: diphenhydramine, Roxanol (morphine)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
lorazepam ↔ trazodone
Applies to: lorazepam, trazodone
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
diphenhydramine ↔ trazodone
Applies to: diphenhydramine, trazodone
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
morphine ↔ trazodone
Applies to: Roxanol (morphine), trazodone
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
lorazepam ↔ zolpidem
Applies to: lorazepam, Ambien (zolpidem)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
diphenhydramine ↔ zolpidem
Applies to: diphenhydramine, Ambien (zolpidem)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
metoclopramide ↔ zolpidem
Applies to: metoclopramide, Ambien (zolpidem)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
morphine ↔ zolpidem
Applies to: Roxanol (morphine), Ambien (zolpidem)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
trazodone ↔ zolpidem
Applies to: trazodone, Ambien (zolpidem)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
clonidine ↔ cyclobenzaprine
Applies to: clonidine, Flexeril (cyclobenzaprine)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
lorazepam ↔ cyclobenzaprine
Applies to: lorazepam, Flexeril (cyclobenzaprine)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
metoclopramide ↔ cyclobenzaprine
Applies to: metoclopramide, Flexeril (cyclobenzaprine)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
morphine ↔ cyclobenzaprine
Applies to: Roxanol (morphine), Flexeril (cyclobenzaprine)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
trazodone ↔ cyclobenzaprine
Applies to: trazodone, Flexeril (cyclobenzaprine)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
zolpidem ↔ cyclobenzaprine
Applies to: Ambien (zolpidem), Flexeril (cyclobenzaprine)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
lorazepam ↔ hydrocodone
Applies to: lorazepam, Lortab 7.5/500 (acetaminophen/hydrocodone)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
diphenhydramine ↔ hydrocodone
Applies to: diphenhydramine, Lortab 7.5/500 (acetaminophen/hydrocodone)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
morphine ↔ hydrocodone
Applies to: Roxanol (morphine), Lortab 7.5/500 (acetaminophen/hydrocodone)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
trazodone ↔ hydrocodone
Applies to: trazodone, Lortab 7.5/500 (acetaminophen/hydrocodone)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
zolpidem ↔ hydrocodone
Applies to: Ambien (zolpidem), Lortab 7.5/500 (acetaminophen/hydrocodone)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
cyclobenzaprine ↔ hydrocodone
Applies to: Flexeril (cyclobenzaprine), Lortab 7.5/500 (acetaminophen/hydrocodone)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
clonidine ↔ tramadol
Applies to: clonidine, tramadol
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
lorazepam ↔ tramadol
Applies to: lorazepam, tramadol
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
diphenhydramine ↔ tramadol
Applies to: diphenhydramine, tramadol
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
zolpidem ↔ tramadol
Applies to: Ambien (zolpidem), tramadol
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
lorazepam ↔ citalopram
Applies to: lorazepam, Celexa (citalopram)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
diphenhydramine ↔ citalopram
Applies to: diphenhydramine, Celexa (citalopram)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
morphine ↔ citalopram
Applies to: Roxanol (morphine), Celexa (citalopram)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
zolpidem ↔ citalopram
Applies to: Ambien (zolpidem), Celexa (citalopram)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
cyclobenzaprine ↔ citalopram
Applies to: Flexeril (cyclobenzaprine), Celexa (citalopram)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
hydrocodone ↔ citalopram
Applies to: Lortab 7.5/500 (acetaminophen/hydrocodone), Celexa (citalopram)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
lorazepam ↔ escitalopram
Applies to: lorazepam, Lexapro (escitalopram)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
diphenhydramine ↔ escitalopram
Applies to: diphenhydramine, Lexapro (escitalopram)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
morphine ↔ escitalopram
Applies to: Roxanol (morphine), Lexapro (escitalopram)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
zolpidem ↔ escitalopram
Applies to: Ambien (zolpidem), Lexapro (escitalopram)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
cyclobenzaprine ↔ escitalopram
Applies to: Flexeril (cyclobenzaprine), Lexapro (escitalopram)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
hydrocodone ↔ escitalopram
Applies to: Lortab 7.5/500 (acetaminophen/hydrocodone), Lexapro (escitalopram)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
citalopram ↔ escitalopram
Applies to: Celexa (citalopram), Lexapro (escitalopram)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
clonidine ↔ pregabalin
Applies to: clonidine, Lyrica (pregabalin)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
lorazepam ↔ pregabalin
Applies to: lorazepam, Lyrica (pregabalin)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
diphenhydramine ↔ pregabalin
Applies to: diphenhydramine, Lyrica (pregabalin)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
metoclopramide ↔ pregabalin
Applies to: metoclopramide, Lyrica (pregabalin)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
morphine ↔ pregabalin
Applies to: Roxanol (morphine), Lyrica (pregabalin)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
trazodone ↔ pregabalin
Applies to: trazodone, Lyrica (pregabalin)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
zolpidem ↔ pregabalin
Applies to: Ambien (zolpidem), Lyrica (pregabalin)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
cyclobenzaprine ↔ pregabalin
Applies to: Flexeril (cyclobenzaprine), Lyrica (pregabalin)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
hydrocodone ↔ pregabalin
Applies to: Lortab 7.5/500 (acetaminophen/hydrocodone), Lyrica (pregabalin)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
tramadol ↔ pregabalin
Applies to: tramadol, Lyrica (pregabalin)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
citalopram ↔ pregabalin
Applies to: Celexa (citalopram), Lyrica (pregabalin)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
escitalopram ↔ pregabalin
Applies to: Lexapro (escitalopram), Lyrica (pregabalin)
MONITOR: Central nervous system- and/or respiratory-depressant effects may be additively or synergistically increased in patients taking multiple drugs that cause these effects, especially in elderly or debilitated patients.MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.
metoprolol ↔ citalopram
Applies to: metoprolol, Celexa (citalopram)
MONITOR: Limited clinical data suggest that selective serotonin reuptake inhibitors (SSRIs) may potentiate the pharmacologic effects of some beta-blockers. There have been case reports of patients stabilized on beta-blocker therapy who developed bradycardia, hypotension, and complete heart block following the addition of a SSRI, subsequently requiring discontinuation of one or both agents and/or institution of a permanent pacemaker. The interaction is also corroborated by data from in vitro and clinical studies involving paroxetine and metoprolol conducted by one group of investigators. The proposed mechanism is SSRI inhibition (competitive and/or noncompetitive) of CYP450 2D6, the isoenzyme responsible for the metabolic clearance of beta-blockers such as carvedilol, labetalol, metoprolol, nebivolol, propranolol, and timolol. Paroxetine and norfluoxetine (the active metabolite of fluoxetine), in particular, are potent inhibitors of CYP450 2D6 and may be more likely than other SSRIs to cause the interaction. On the other hand, fluvoxamine is a potent inhibitor of CYP450 1A2 and may significantly interact with propranolol, which is a substrate of both CYP450 2D6 and 1A2.MANAGEMENT: During concomitant therapy with SSRIs, a lower initial dosage and more cautious titration of the beta-blocker may be appropriate. Cardiac function should be closely monitored and the beta-blocker dosage adjusted accordingly, particularly following initiation, discontinuation or change of dosage of SSRI in patients who are stabilized on their beta-blocker regimen. Due to the long half-life of fluoxetine and its active metabolite, norfluoxetine, the risk of an interaction may exist for an extended period (up to several weeks) after discontinuation of fluoxetine. To avoid the interaction, use of beta-blockers that are primarily eliminated by the kidney such as atenolol, acebutolol, betaxolol, carteolol, and nadolol may be considered.
metoprolol ↔ calcium acetate
Applies to: metoprolol, PhosLo Gelcap (calcium acetate)
ADJUST DOSING INTERVAL: Concurrent administration with calcium salts may decrease the oral bioavailability of atenolol and possibly other beta-blockers. The exact mechanism of interaction is unknown. In six healthy subjects, calcium 500 mg (as lactate, carbonate, and gluconate) reduced the mean peak plasma concentration (Cmax) and area under the concentration-time curve (AUC) of atenolol (100 mg) by 51% and 32%, respectively. The elimination half-life increased by 44%. Twelve hours after the combination, beta-blocking activity (as indicated by inhibition of exercise tachycardia) was reduced compared to that with atenolol alone. However, during a 4-week treatment in six hypertensive patients, there was no difference in blood pressure values between treatments. The investigators suggest that prolongation of the elimination half-life induced by calcium coadministration may have led to atenolol cumulation during long-term dosing, which compensated for the reduced bioavailability.MANAGEMENT: It may help to separate the administration times of beta-blockers and calcium products by at least 2 hours. Patients should be monitored for potentially diminished beta-blocking effects following the addition of calcium therapy.
sulfamethoxazole ↔ insulin lispro
Applies to: Bactrim DS (sulfamethoxazole/trimethoprim), Humalog (insulin lispro)
MONITOR: The hypoglycemic effect of insulin may be potentiated by certain drugs, including ACE inhibitors, amylin analogs, anabolic steroids, fibrates, monoamine oxidase inhibitors (MAOIs), salicylates, selective serotonin reuptake inhibitors (SSRIs), sulfonamides, disopyramide, propoxyphene, quinine, quinidine, and ginseng. These drugs may increase the risk of hypoglycemia by enhancing insulin sensitivity (ACE inhibitors, fibrates, ginseng); stimulating insulin secretion (salicylates, disopyramide, quinine, quinidine, MAOIs, ginseng); increasing peripheral glucose utilization (SSRIs, insulin-like growth factor); inhibiting gluconeogenesis (SSRIs, MAOIs, insulin-like growth factor); slowing the rate of gastric emptying (amylin analogs); and/or suppressing postprandial glucagon secretion (amylin analogs). Clinical hypoglycemia has been reported during use of some of these agents alone or with insulin and/or insulin secretagogues.MANAGEMENT: Close monitoring for the development of hypoglycemia is recommended if these drugs are coadministered with insulin, particularly in patients with advanced age and/or renal impairment. The insulin dosage may require adjustment if an interaction is suspected. Patients should be apprised of the signs and symptoms of hypoglycemia (e.g., headache, dizziness, drowsiness, nausea, hunger, tremor, weakness, sweating, palpitations), how to treat it, and to contact their physician if it occurs. Patients should be observed for loss of glycemic control when these drugs are withdrawn.
citalopram ↔ insulin lispro
Applies to: Celexa (citalopram), Humalog (insulin lispro)
MONITOR: The hypoglycemic effect of insulin may be potentiated by certain drugs, including ACE inhibitors, amylin analogs, anabolic steroids, fibrates, monoamine oxidase inhibitors (MAOIs), salicylates, selective serotonin reuptake inhibitors (SSRIs), sulfonamides, disopyramide, propoxyphene, quinine, quinidine, and ginseng. These drugs may increase the risk of hypoglycemia by enhancing insulin sensitivity (ACE inhibitors, fibrates, ginseng); stimulating insulin secretion (salicylates, disopyramide, quinine, quinidine, MAOIs, ginseng); increasing peripheral glucose utilization (SSRIs, insulin-like growth factor); inhibiting gluconeogenesis (SSRIs, MAOIs, insulin-like growth factor); slowing the rate of gastric emptying (amylin analogs); and/or suppressing postprandial glucagon secretion (amylin analogs). Clinical hypoglycemia has been reported during use of some of these agents alone or with insulin and/or insulin secretagogues.MANAGEMENT: Close monitoring for the development of hypoglycemia is recommended if these drugs are coadministered with insulin, particularly in patients with advanced age and/or renal impairment. The insulin dosage may require adjustment if an interaction is suspected. Patients should be apprised of the signs and symptoms of hypoglycemia (e.g., headache, dizziness, drowsiness, nausea, hunger, tremor, weakness, sweating, palpitations), how to treat it, and to contact their physician if it occurs. Patients should be observed for loss of glycemic control when these drugs are withdrawn.
sulfamethoxazole ↔ insulin glargine
Applies to: Bactrim DS (sulfamethoxazole/trimethoprim), Lantus (insulin glargine)
MONITOR: The hypoglycemic effect of insulin may be potentiated by certain drugs, including ACE inhibitors, amylin analogs, anabolic steroids, fibrates, monoamine oxidase inhibitors (MAOIs), salicylates, selective serotonin reuptake inhibitors (SSRIs), sulfonamides, disopyramide, propoxyphene, quinine, quinidine, and ginseng. These drugs may increase the risk of hypoglycemia by enhancing insulin sensitivity (ACE inhibitors, fibrates, ginseng); stimulating insulin secretion (salicylates, disopyramide, quinine, quinidine, MAOIs, ginseng); increasing peripheral glucose utilization (SSRIs, insulin-like growth factor); inhibiting gluconeogenesis (SSRIs, MAOIs, insulin-like growth factor); slowing the rate of gastric emptying (amylin analogs); and/or suppressing postprandial glucagon secretion (amylin analogs). Clinical hypoglycemia has been reported during use of some of these agents alone or with insulin and/or insulin secretagogues.MANAGEMENT: Close monitoring for the development of hypoglycemia is recommended if these drugs are coadministered with insulin, particularly in patients with advanced age and/or renal impairment. The insulin dosage may require adjustment if an interaction is suspected. Patients should be apprised of the signs and symptoms of hypoglycemia (e.g., headache, dizziness, drowsiness, nausea, hunger, tremor, weakness, sweating, palpitations), how to treat it, and to contact their physician if it occurs. Patients should be observed for loss of glycemic control when these drugs are withdrawn.
citalopram ↔ insulin glargine
Applies to: Celexa (citalopram), Lantus (insulin glargine)
MONITOR: The hypoglycemic effect of insulin may be potentiated by certain drugs, including ACE inhibitors, amylin analogs, anabolic steroids, fibrates, monoamine oxidase inhibitors (MAOIs), salicylates, selective serotonin reuptake inhibitors (SSRIs), sulfonamides, disopyramide, propoxyphene, quinine, quinidine, and ginseng. These drugs may increase the risk of hypoglycemia by enhancing insulin sensitivity (ACE inhibitors, fibrates, ginseng); stimulating insulin secretion (salicylates, disopyramide, quinine, quinidine, MAOIs, ginseng); increasing peripheral glucose utilization (SSRIs, insulin-like growth factor); inhibiting gluconeogenesis (SSRIs, MAOIs, insulin-like growth factor); slowing the rate of gastric emptying (amylin analogs); and/or suppressing postprandial glucagon secretion (amylin analogs). Clinical hypoglycemia has been reported during use of some of these agents alone or with insulin and/or insulin secretagogues.MANAGEMENT: Close monitoring for the development of hypoglycemia is recommended if these drugs are coadministered with insulin, particularly in patients with advanced age and/or renal impairment. The insulin dosage may require adjustment if an interaction is suspected. Patients should be apprised of the signs and symptoms of hypoglycemia (e.g., headache, dizziness, drowsiness, nausea, hunger, tremor, weakness, sweating, palpitations), how to treat it, and to contact their physician if it occurs. Patients should be observed for loss of glycemic control when these drugs are withdrawn.
insulin lispro ↔ escitalopram
Applies to: Humalog (insulin lispro), Lexapro (escitalopram)
MONITOR: The hypoglycemic effect of insulin may be potentiated by certain drugs, including ACE inhibitors, amylin analogs, anabolic steroids, fibrates, monoamine oxidase inhibitors (MAOIs), salicylates, selective serotonin reuptake inhibitors (SSRIs), sulfonamides, disopyramide, propoxyphene, quinine, quinidine, and ginseng. These drugs may increase the risk of hypoglycemia by enhancing insulin sensitivity (ACE inhibitors, fibrates, ginseng); stimulating insulin secretion (salicylates, disopyramide, quinine, quinidine, MAOIs, ginseng); increasing peripheral glucose utilization (SSRIs, insulin-like growth factor); inhibiting gluconeogenesis (SSRIs, MAOIs, insulin-like growth factor); slowing the rate of gastric emptying (amylin analogs); and/or suppressing postprandial glucagon secretion (amylin analogs). Clinical hypoglycemia has been reported during use of some of these agents alone or with insulin and/or insulin secretagogues.MANAGEMENT: Close monitoring for the development of hypoglycemia is recommended if these drugs are coadministered with insulin, particularly in patients with advanced age and/or renal impairment. The insulin dosage may require adjustment if an interaction is suspected. Patients should be apprised of the signs and symptoms of hypoglycemia (e.g., headache, dizziness, drowsiness, nausea, hunger, tremor, weakness, sweating, palpitations), how to treat it, and to contact their physician if it occurs. Patients should be observed for loss of glycemic control when these drugs are withdrawn.
insulin glargine ↔ escitalopram
Applies to: Lantus (insulin glargine), Lexapro (escitalopram)
MONITOR: The hypoglycemic effect of insulin may be potentiated by certain drugs, including ACE inhibitors, amylin analogs, anabolic steroids, fibrates, monoamine oxidase inhibitors (MAOIs), salicylates, selective serotonin reuptake inhibitors (SSRIs), sulfonamides, disopyramide, propoxyphene, quinine, quinidine, and ginseng. These drugs may increase the risk of hypoglycemia by enhancing insulin sensitivity (ACE inhibitors, fibrates, ginseng); stimulating insulin secretion (salicylates, disopyramide, quinine, quinidine, MAOIs, ginseng); increasing peripheral glucose utilization (SSRIs, insulin-like growth factor); inhibiting gluconeogenesis (SSRIs, MAOIs, insulin-like growth factor); slowing the rate of gastric emptying (amylin analogs); and/or suppressing postprandial glucagon secretion (amylin analogs). Clinical hypoglycemia has been reported during use of some of these agents alone or with insulin and/or insulin secretagogues.MANAGEMENT: Close monitoring for the development of hypoglycemia is recommended if these drugs are coadministered with insulin, particularly in patients with advanced age and/or renal impairment. The insulin dosage may require adjustment if an interaction is suspected. Patients should be apprised of the signs and symptoms of hypoglycemia (e.g., headache, dizziness, drowsiness, nausea, hunger, tremor, weakness, sweating, palpitations), how to treat it, and to contact their physician if it occurs. Patients should be observed for loss of glycemic control when these drugs are withdrawn.
doxycycline ↔ insulin lispro
Applies to: doxycycline, Humalog (insulin lispro)
MONITOR: Tetracyclines may enhance the hypoglycemic effect of insulin by increasing tissue sensitivity to exogenous insulin.MANAGEMENT: Blood glucose should be monitored closely whenever tetracyclines are prescribed to patients on insulin, especially if they are elderly or have renal impairment. The insulin dosage may require adjustment if an interaction is suspected. Patients should be apprised of the signs and symptoms of hypoglycemia (e.g., headache, dizziness, drowsiness, nausea, hunger, tremor, weakness, sweating, palpitations), how to treat it, and to contact their physician if it occurs.
doxycycline ↔ insulin glargine
Applies to: doxycycline, Lantus (insulin glargine)
MONITOR: Tetracyclines may enhance the hypoglycemic effect of insulin by increasing tissue sensitivity to exogenous insulin.MANAGEMENT: Blood glucose should be monitored closely whenever tetracyclines are prescribed to patients on insulin, especially if they are elderly or have renal impairment. The insulin dosage may require adjustment if an interaction is suspected. Patients should be apprised of the signs and symptoms of hypoglycemia (e.g., headache, dizziness, drowsiness, nausea, hunger, tremor, weakness, sweating, palpitations), how to treat it, and to contact their physician if it occurs.
omeprazole ↔ multivitamin with iron
Applies to: omeprazole, Dialyvite (multivitamin with iron)
MONITOR: The profound hypochlorhydria induced by proton pump inhibitors (PPIs) may impair the gastrointestinal absorption of nonheme iron, a process that is dependent on an acidic environment. The interaction was suspected in two patients with iron deficiency anemia due to gastrointestinal blood loss that were unresponsive to oral iron replacement therapy, even after the bleeding had apparently stopped. Both patients had been on omeprazole for six months while being treated with ferrous sulfate. An iron-loading test was performed on one of the patients and indicated iron malabsorption. Within two months after discontinuation of omeprazole, notable improvements in hemoglobin level and mean corpuscular volume (MCV) were observed in both patients, and iron absorption was significantly increased in the patient who underwent absorption testing. In a case review of patients with hereditary hemochromatosis treated at one institution, investigators observed a reduced requirement for maintenance phlebotomy in seven patients following initiation of PPI therapy (mean 2.5 L blood removed/year before PPI therapy vs. 0.5 L/year during PPI therapy), presumably due to reduced tissue iron accumulation stemming from impaired absorption of dietary nonheme iron. Mean annual phlebotomy requirement during PPI therapy in these patients was also lower than that in controls who had never taken a PPI (mean 2.3 L blood removed/year). The same group of investigators also studied iron absorption in 14 patients fed an iron-loaded meal before and after PPI therapy for one week. PPI therapy was associated with a 51% reduction in area under the serum iron concentration-time curve (AUC 0 to 4 hours); a 55% reduction in maximum increase of serum iron following ingestion of iron-loaded meal; and a 46% reduction in percent recovery of administered iron at peak serum iron concentration. Interestingly, the interaction has not been reported in healthy, iron-replete individuals. In a study of 109 patients with Zollinger-Ellison syndrome who had not undergone gastric resection, omeprazole treatment for an average of 5.7 years did not significantly decrease body iron stores or cause iron deficiency compared to H2-receptor antagonist therapy or no gastric acid-suppressant treatment. It is possible that the interaction may not affect people with healthy iron stores because of compensation by dietary heme iron, which typically comprises only a small fraction of dietary iron but whose absorption is not dependent on gastrointestinal pH. In contrast, dietary heme iron alone may not be sufficient to restore normal iron balance in patients with anemia or those with defective regulatory mechanisms of iron absorption.MANAGEMENT: Patients with iron deficiency may not respond adequately to oral iron replacement therapy during coadministration of proton pump inhibitors. If an interaction is suspected after ruling out other causes, it may be appropriate to discontinue the proton pump inhibitor or consider administering iron parenterally.
multivitamin with iron ↔ iron sucrose
Applies to: Dialyvite (multivitamin with iron), Venofer (iron sucrose)
GENERALLY AVOID: Parenteral iron therapy may reduce the absorption of concomitantly administered oral iron preparations.MANAGEMENT: Parenteral iron preparations should not be administered concomitantly with oral iron preparations. Patients should wait at least 5 days after stopping parenteral iron therapy before taking oral iron supplements.
diphenhydramine ↔ cyclobenzaprine
Applies to: diphenhydramine, Flexeril (cyclobenzaprine)
MONITOR: Agents with anticholinergic properties (e.g., sedating antihistamines; antispasmodics; neuroleptics; phenothiazines; skeletal muscle relaxants; tricyclic antidepressants; disopyramide) may have additive effects when used in combination. Excessive parasympatholytic effects may result in paralytic ileus, hyperthermia, heat stroke, and the anticholinergic intoxication syndrome. Peripheral symptoms of intoxication commonly include mydriasis, blurred vision, flushed face, fever, dry skin and mucous membranes, tachycardia, urinary retention, and constipation. Central symptoms may include memory loss, disorientation, incoherence, hallucinations, psychosis, delirium, hyperactivity, twitching or jerking movements, stereotypy, and seizures. Central nervous system-depressant effects may also be additively or synergistically increased when these agents are combined, especially in elderly or debilitated patients. Use of neuroleptics in combination with other neuroleptics or anticholinergic agents may increase the risk of tardive dyskinesia.MANAGEMENT: Caution is advised when agents with anticholinergic properties are combined, particularly in the elderly and those with underlying organic brain disease, who tend to be more sensitive to the central anticholinergic effects of these drugs and in whom toxicity symptoms may be easily overlooked. Patients should be advised to notify their physician promptly if they experience potential symptoms of anticholinergic intoxication such as abdominal pain, fever, heat intolerance, blurred vision, confusion, and/or hallucinations. Ambulatory patients should be counseled to avoid activities requiring mental alertness until they know how these agents affect them. A reduction in anticholinergic dosages may be necessary if excessive adverse effects develop.
albuterol ↔ insulin lispro
Applies to: Combivent (albuterol/ipratropium), Humalog (insulin lispro)
MONITOR: The efficacy of oral hypoglycemic agents and insulin may be diminished by certain drugs, including thiazides and other diuretics, corticosteroids, estrogens, progestins, thyroid hormones, human growth hormone, phenothiazines, atypical antipsychotics, sympathomimetic amines, protease inhibitors, phenytoin, megestrol, danazol, isoniazid, asparaginase, pegaspargase, diazoxide, temsirolimus, as well as pharmacologic dosages of nicotinic acid and adrenocorticotropic agents. These drugs may interfere with blood glucose control because they can cause hyperglycemia, glucose intolerance, new-onset diabetes mellitus, and/or exacerbation of preexisting diabetes.MANAGEMENT: Close clinical monitoring of glycemic control is recommended if these drugs are coadministered with antidiabetic agents. Likewise, patients should be observed for hypoglycemia when these drugs are withdrawn from their therapeutic regimen. Dose adjustments of the hypoglycemic agent may be required.
albuterol ↔ insulin glargine
Applies to: Combivent (albuterol/ipratropium), Lantus (insulin glargine)
MONITOR: The efficacy of oral hypoglycemic agents and insulin may be diminished by certain drugs, including thiazides and other diuretics, corticosteroids, estrogens, progestins, thyroid hormones, human growth hormone, phenothiazines, atypical antipsychotics, sympathomimetic amines, protease inhibitors, phenytoin, megestrol, danazol, isoniazid, asparaginase, pegaspargase, diazoxide, temsirolimus, as well as pharmacologic dosages of nicotinic acid and adrenocorticotropic agents. These drugs may interfere with blood glucose control because they can cause hyperglycemia, glucose intolerance, new-onset diabetes mellitus, and/or exacerbation of preexisting diabetes.MANAGEMENT: Close clinical monitoring of glycemic control is recommended if these drugs are coadministered with antidiabetic agents. Likewise, patients should be observed for hypoglycemia when these drugs are withdrawn from their therapeutic regimen. Dose adjustments of the hypoglycemic agent may be required.
omeprazole ↔ citalopram
Applies to: omeprazole, Celexa (citalopram)
MONITOR: CYP450 2C19 is one of the two primary enzymes responsible for the metabolism of citalopram. Concomitant use of citalopram with drugs which inhibit CYP450 2C19 enzymes may decrease the clearance of citalopram. Caution is advised that higher citalopram blood levels may exist if citalopram is to be administered with a enzyme inhibitor.MANAGEMENT: Dosage adjustments as well as clinical and laboratory monitoring may be appropriate whenever an enzyme inhibitor is added to or withdrawn from therapy. Close monitoring is recommended for signs and symptoms of excessive serotonergic activity such as CNS irritability, altered consciousness, confusion, myoclonus, ataxia, abdominal cramping, hyperpyrexia, shivering, pupillary dilation, diaphoresis, hypertension, and tachycardia.
metoclopramide ↔ trazodone
Applies to: metoclopramide, trazodone
MONITOR: Coadministration of metoclopramide with serotonin reuptake inhibitors has been associated with development of the serotonin syndrome and severe extrapyramidal reactions. The exact mechanism is unknown but may involve a pharmacodynamic interaction between serotonergic and antidopaminergic effects of the drugs. A pharmacokinetic interaction is also possible, since metoclopramide and most serotonin reuptake inhibitors are primarily or at least partially metabolized by the CYP450 2D6 isoenzyme. Theoretically, competitive and/or noncompetitive inhibition may lead to elevated plasma levels of one or both drugs, resulting in excessive central serotonergic and antidopaminergic effects. A pharmacokinetic study conducted in 24 young, healthy, nonsmoking volunteers found that administration of a single 20 mg dose of metoclopramide following pretreatment with fluoxetine (60 mg/day for 8 days) resulted in a 42% and 89% increase in metoclopramide peak plasma concentration (Cmax) and systemic exposure (AUC), respectively, compared to metoclopramide administered alone. In a published case report, a 72-year-old woman treated with sertraline and a 32-year-old woman treated with venlafaxine developed movement disorders and symptoms consistent with the serotonin syndrome shortly after single doses of metoclopramide. Both cases resolved following treatment with diazepam, and the patients resumed their sertraline and venlafaxine therapy without further incident. Serotonin syndrome is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5-HT1A and 2A receptors. Symptoms of the serotonin syndrome may include mental status changes such as irritability, altered consciousness, confusion, hallucinations, and coma; autonomic dysfunction such as tachycardia, hyperthermia, diaphoresis, shivering, blood pressure lability, and mydriasis; neuromuscular abnormalities such as hyperreflexia, myoclonus, tremor, rigidity, and ataxia; and gastrointestinal symptoms such as abdominal cramping, nausea, vomiting, and diarrhea.MANAGEMENT: Caution is advised if metoclopramide is prescribed in combination with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). Patients should be monitored for symptoms of the serotonin syndrome as well as development of extrapyramidal reactions such as involuntary twitching of the jaw and limbs, teeth clenching, severe jerking, trismus, and tongue and neck stiffness. If serotonin syndrome develops or is suspected during the course of therapy, all serotonergic agents should be discontinued immediately and supportive care rendered as necessary. Moderately ill patients may also benefit from the administration of a serotonin antagonist (e.g., cyproheptadine, chlorpromazine). Severe cases should be managed under consultation with a toxicologist and may require sedation, neuromuscular paralysis, intubation, and mechanical ventilation in addition to the other measures.
metoclopramide ↔ citalopram
Applies to: metoclopramide, Celexa (citalopram)
MONITOR: Coadministration of metoclopramide with serotonin reuptake inhibitors has been associated with development of the serotonin syndrome and severe extrapyramidal reactions. The exact mechanism is unknown but may involve a pharmacodynamic interaction between serotonergic and antidopaminergic effects of the drugs. A pharmacokinetic interaction is also possible, since metoclopramide and most serotonin reuptake inhibitors are primarily or at least partially metabolized by the CYP450 2D6 isoenzyme. Theoretically, competitive and/or noncompetitive inhibition may lead to elevated plasma levels of one or both drugs, resulting in excessive central serotonergic and antidopaminergic effects. A pharmacokinetic study conducted in 24 young, healthy, nonsmoking volunteers found that administration of a single 20 mg dose of metoclopramide following pretreatment with fluoxetine (60 mg/day for 8 days) resulted in a 42% and 89% increase in metoclopramide peak plasma concentration (Cmax) and systemic exposure (AUC), respectively, compared to metoclopramide administered alone. In a published case report, a 72-year-old woman treated with sertraline and a 32-year-old woman treated with venlafaxine developed movement disorders and symptoms consistent with the serotonin syndrome shortly after single doses of metoclopramide. Both cases resolved following treatment with diazepam, and the patients resumed their sertraline and venlafaxine therapy without further incident. Serotonin syndrome is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5-HT1A and 2A receptors. Symptoms of the serotonin syndrome may include mental status changes such as irritability, altered consciousness, confusion, hallucinations, and coma; autonomic dysfunction such as tachycardia, hyperthermia, diaphoresis, shivering, blood pressure lability, and mydriasis; neuromuscular abnormalities such as hyperreflexia, myoclonus, tremor, rigidity, and ataxia; and gastrointestinal symptoms such as abdominal cramping, nausea, vomiting, and diarrhea.MANAGEMENT: Caution is advised if metoclopramide is prescribed in combination with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). Patients should be monitored for symptoms of the serotonin syndrome as well as development of extrapyramidal reactions such as involuntary twitching of the jaw and limbs, teeth clenching, severe jerking, trismus, and tongue and neck stiffness. If serotonin syndrome develops or is suspected during the course of therapy, all serotonergic agents should be discontinued immediately and supportive care rendered as necessary. Moderately ill patients may also benefit from the administration of a serotonin antagonist (e.g., cyproheptadine, chlorpromazine). Severe cases should be managed under consultation with a toxicologist and may require sedation, neuromuscular paralysis, intubation, and mechanical ventilation in addition to the other measures.
metoclopramide ↔ escitalopram
Applies to: metoclopramide, Lexapro (escitalopram)
MONITOR: Coadministration of metoclopramide with serotonin reuptake inhibitors has been associated with development of the serotonin syndrome and severe extrapyramidal reactions. The exact mechanism is unknown but may involve a pharmacodynamic interaction between serotonergic and antidopaminergic effects of the drugs. A pharmacokinetic interaction is also possible, since metoclopramide and most serotonin reuptake inhibitors are primarily or at least partially metabolized by the CYP450 2D6 isoenzyme. Theoretically, competitive and/or noncompetitive inhibition may lead to elevated plasma levels of one or both drugs, resulting in excessive central serotonergic and antidopaminergic effects. A pharmacokinetic study conducted in 24 young, healthy, nonsmoking volunteers found that administration of a single 20 mg dose of metoclopramide following pretreatment with fluoxetine (60 mg/day for 8 days) resulted in a 42% and 89% increase in metoclopramide peak plasma concentration (Cmax) and systemic exposure (AUC), respectively, compared to metoclopramide administered alone. In a published case report, a 72-year-old woman treated with sertraline and a 32-year-old woman treated with venlafaxine developed movement disorders and symptoms consistent with the serotonin syndrome shortly after single doses of metoclopramide. Both cases resolved following treatment with diazepam, and the patients resumed their sertraline and venlafaxine therapy without further incident. Serotonin syndrome is a rare but serious and potentially fatal condition thought to result from hyperstimulation of brainstem 5-HT1A and 2A receptors. Symptoms of the serotonin syndrome may include mental status changes such as irritability, altered consciousness, confusion, hallucinations, and coma; autonomic dysfunction such as tachycardia, hyperthermia, diaphoresis, shivering, blood pressure lability, and mydriasis; neuromuscular abnormalities such as hyperreflexia, myoclonus, tremor, rigidity, and ataxia; and gastrointestinal symptoms such as abdominal cramping, nausea, vomiting, and diarrhea.MANAGEMENT: Caution is advised if metoclopramide is prescribed in combination with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). Patients should be monitored for symptoms of the serotonin syndrome as well as development of extrapyramidal reactions such as involuntary twitching of the jaw and limbs, teeth clenching, severe jerking, trismus, and tongue and neck stiffness. If serotonin syndrome develops or is suspected during the course of therapy, all serotonergic agents should be discontinued immediately and supportive care rendered as necessary. Moderately ill patients may also benefit from the administration of a serotonin antagonist (e.g., cyproheptadine, chlorpromazine). Severe cases should be managed under consultation with a toxicologist and may require sedation, neuromuscular paralysis, intubation, and mechanical ventilation in addition to the other measures.
ondansetron ↔ tramadol
Applies to: Zofran (ondansetron), tramadol
MONITOR: Concurrent use of 5-HT3 receptor antagonists may reduce the analgesic efficacy of tramadol. The proposed mechanism is antagonism of serotonin-mediated effects of tramadol at the spinal level. In a randomized, double-blind study of 40 patients undergoing lumbar laminectomy, patients who were administered ondansetron 4 mg at induction of anesthesia required more tramadol postsurgery than control patients who had been given saline. Cumulative tramadol use via a PCA pump was 26% to 35% higher in the ondansetron group the first 4 hours postoperatively and 22% to 25% higher thereafter. Tramadol use on an hourly basis did not differ significantly between the two groups except in the first postoperative hour, probably because of the relatively short plasma half-life of ondansetron. The 4 mg dose of ondansetron did not reduce the 24-hour incidence of postoperative nausea and vomiting.MANAGEMENT: No particular intervention is required. However, the possibility of a diminished therapeutic response to tramadol should be considered during concomitant therapy with 5-HT3 receptor antagonists.
clonidine ↔ budesonide
Applies to: clonidine, Symbicort (budesonide/formoterol)
MONITOR: Corticosteroids may antagonize the effects of antihypertensive medications by causing sodium and fluid retention. These effects may be more common with the natural corticosteroids (cortisone, hydrocortisone) because they have greater mineralocorticoid activity. In addition, some calcium channel blockers such as diltiazem and verapamil may increase corticosteroid plasma levels and effects by inhibiting their clearance via CYP450 3A4 metabolism.MANAGEMENT: Patients on prolonged (i.e., longer than about a week) or high-dose corticosteroid therapy should have blood pressure, electrolyte levels, and body weight monitored regularly, and be observed for the development of edema and congestive heart failure. The dosages of antihypertensive medications may require adjustment.
metoprolol ↔ budesonide
Applies to: metoprolol, Symbicort (budesonide/formoterol)
MONITOR: Corticosteroids may antagonize the effects of antihypertensive medications by causing sodium and fluid retention. These effects may be more common with the natural corticosteroids (cortisone, hydrocortisone) because they have greater mineralocorticoid activity. In addition, some calcium channel blockers such as diltiazem and verapamil may increase corticosteroid plasma levels and effects by inhibiting their clearance via CYP450 3A4 metabolism.MANAGEMENT: Patients on prolonged (i.e., longer than about a week) or high-dose corticosteroid therapy should have blood pressure, electrolyte levels, and body weight monitored regularly, and be observed for the development of edema and congestive heart failure. The dosages of antihypertensive medications may require adjustment.
clonidine ↔ lorazepam
Applies to: clonidine, lorazepam
MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.MANAGEMENT: Caution is advised during coadministration of these agents. Close monitoring for development of hypotension is recommended. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.
clonidine ↔ diphenhydramine
Applies to: clonidine, diphenhydramine
MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.MANAGEMENT: Caution is advised during coadministration of these agents. Close monitoring for development of hypotension is recommended. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.
metoprolol ↔ diphenhydramine
Applies to: metoprolol, diphenhydramine
MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.MANAGEMENT: Caution is advised during coadministration of these agents. Close monitoring for development of hypotension is recommended. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.
clonidine ↔ morphine
Applies to: clonidine, Roxanol (morphine)
MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.MANAGEMENT: Caution is advised during coadministration of these agents. Close monitoring for development of hypotension is recommended. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.
metoprolol ↔ morphine
Applies to: metoprolol, Roxanol (morphine)
MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.MANAGEMENT: Caution is advised during coadministration of these agents. Close monitoring for development of hypotension is recommended. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.
clonidine ↔ trazodone
Applies to: clonidine, trazodone
MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.MANAGEMENT: Caution is advised during coadministration of these agents. Close monitoring for development of hypotension is recommended. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.
metoprolol ↔ trazodone
Applies to: metoprolol, trazodone
MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.MANAGEMENT: Caution is advised during coadministration of these agents. Close monitoring for development of hypotension is recommended. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.
clonidine ↔ zolpidem
Applies to: clonidine, Ambien (zolpidem)
MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.MANAGEMENT: Caution is advised during coadministration of these agents. Close monitoring for development of hypotension is recommended. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.
metoprolol ↔ zolpidem
Applies to: metoprolol, Ambien (zolpidem)
MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.MANAGEMENT: Caution is advised during coadministration of these agents. Close monitoring for development of hypotension is recommended. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.
metoprolol ↔ cyclobenzaprine
Applies to: metoprolol, Flexeril (cyclobenzaprine)
MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.MANAGEMENT: Caution is advised during coadministration of these agents. Close monitoring for development of hypotension is recommended. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.
clonidine ↔ hydrocodone
Applies to: clonidine, Lortab 7.5/500 (acetaminophen/hydrocodone)
MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.MANAGEMENT: Caution is advised during coadministration of these agents. Close monitoring for development of hypotension is recommended. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.
clonidine ↔ citalopram
Applies to: clonidine, Celexa (citalopram)
MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.MANAGEMENT: Caution is advised during coadministration of these agents. Close monitoring for development of hypotension is recommended. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.
clonidine ↔ escitalopram
Applies to: clonidine, Lexapro (escitalopram)
MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.MANAGEMENT: Caution is advised during coadministration of these agents. Close monitoring for development of hypotension is recommended. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.
diphenhydramine ↔ metoclopramide
Applies to: diphenhydramine, metoclopramide
GENERALLY AVOID: Anticholinergic agents reduce or abolish the prokinetic effects of metoclopramide by antagonizing its effects. MANAGEMENT: This combination should generally be avoided, if possible.
ipratropium ↔ metoclopramide
Applies to: Combivent (albuterol/ipratropium), metoclopramide
GENERALLY AVOID: Anticholinergic agents reduce or abolish the prokinetic effects of metoclopramide by antagonizing its effects. MANAGEMENT: This combination should generally be avoided, if possible.
albuterol ↔ ondansetron
Applies to: Combivent (albuterol/ipratropium), Zofran (ondansetron)
MONITOR: Beta-2 adrenergic agonists can cause dose-related prolongation of the QT interval and potassium loss. Theoretically, coadministration with other agents that can prolong the QT interval may result in elevated risk of ventricular arrhythmias, including ventricular tachycardia and torsade de pointes, because of additive arrhythmogenic potential related to their effects on cardiac conduction. In general, the risk of an individual agent or a combination of agents causing ventricular arrhythmia in association with QT prolongation is largely unpredictable but may be increased by certain underlying risk factors such as congenital long QT syndrome, cardiac disease, and electrolyte disturbances (e.g., hypokalemia, hypomagnesemia). In addition, the extent of drug-induced QT prolongation is dependent on the particular drug(s) involved and dosage(s) of the drug(s). Clinically significant prolongation of QT interval and hypokalemia occur infrequently when beta-2 adrenergic agonists are inhaled at normally recommended dosages. However, these effects may be more common when the drugs are administered systemically or when recommended dosages are exceeded.MANAGEMENT: Caution is advised if beta-2 adrenergic agonists are used in combination with other drugs that prolong the QT interval, including class IA and III antiarrhythmic agents, certain neuroleptic agents, phenothiazines, tricyclic antidepressants, quinolones, ketolide and macrolide antibiotics, and cisapride. Patients should be advised to seek medical attention if they experience symptoms that could indicate the occurrence of torsades de pointes such as dizziness, palpitations, or syncope.
ondansetron ↔ formoterol
Applies to: Zofran (ondansetron), Symbicort (budesonide/formoterol)
MONITOR: Beta-2 adrenergic agonists can cause dose-related prolongation of the QT interval and potassium loss. Theoretically, coadministration with other agents that can prolong the QT interval may result in elevated risk of ventricular arrhythmias, including ventricular tachycardia and torsade de pointes, because of additive arrhythmogenic potential related to their effects on cardiac conduction. In general, the risk of an individual agent or a combination of agents causing ventricular arrhythmia in association with QT prolongation is largely unpredictable but may be increased by certain underlying risk factors such as congenital long QT syndrome, cardiac disease, and electrolyte disturbances (e.g., hypokalemia, hypomagnesemia). In addition, the extent of drug-induced QT prolongation is dependent on the particular drug(s) involved and dosage(s) of the drug(s). Clinically significant prolongation of QT interval and hypokalemia occur infrequently when beta-2 adrenergic agonists are inhaled at normally recommended dosages. However, these effects may be more common when the drugs are administered systemically or when recommended dosages are exceeded.MANAGEMENT: Caution is advised if beta-2 adrenergic agonists are used in combination with other drugs that prolong the QT interval, including class IA and III antiarrhythmic agents, certain neuroleptic agents, phenothiazines, tricyclic antidepressants, quinolones, ketolide and macrolide antibiotics, and cisapride. Patients should be advised to seek medical attention if they experience symptoms that could indicate the occurrence of torsades de pointes such as dizziness, palpitations, or syncope.
metoprolol ↔ albuterol
Applies to: metoprolol, Combivent (albuterol/ipratropium)
GENERALLY AVOID: Although cardioselective beta-blockers do not generally inhibit the bronchodilating effect of beta-2 adrenergic agonists, they may worsen pulmonary function in patients with asthma or other obstructive airway diseases. Cardioselective beta-blockers can occasionally precipitate acute bronchospasm in these patients, despite relative selectivity for beta-1 receptors in cardiac tissues. Presumably, beta-1 selectivity is dose-dependent and may be lost given a sufficient dose of the beta-blocker in susceptible patients. Other mechanisms may also be involved in bronchoconstriction that are unrelated to beta-2 blockade--for example, their effects on cholinergic M2 receptors and alpha-1 adrenoreceptors. Numerous single- and multiple-dose studies have been conducted in asthmatic and COPD patients with various cardioselective beta-blockers, including acebutolol, atenolol, bisoprolol, celiprolol, metoprolol, and nebivolol. Some reported no significant effects on pulmonary function or bronchodilator response to beta-2 adrenergic agonists, while others reported some negative effects on pulmonary function and/or airway hyperresponsiveness. Overall, a meta-analysis of more than two dozen studies found that use of cardioselective beta-blockers in patients with mild to moderate reversible airway disease produced no adverse respiratory effects or decreased responsiveness to beta-2 agonists in the short term. A meta-analysis of 19 studies conducted in patients with COPD by the same group of investigators reported similar results. However, little data exist regarding their safety during chronic use or use in patients with severe respiratory disease. There have been reports of worsening asthma and bronchospasm in patients receiving cardioselective beta-blockers including betaxolol (both systemic and ophthalmic) and esmolol. Several studies have suggested enhanced bronchosparing effects of celiprolol over other cardioselective beta-blockers due to its partial beta-2 agonistic and alpha-2 blocking activities. However, one study found no difference between celiprolol and nebivolol. A few studies also suggested a lower degree of beta-1 selectivity for acebutolol compared to other cardioselective beta-blockers. The clinical significance is unknown. MANAGEMENT: Beta-blockers, including those with relative cardioselectivity, should generally be avoided in patients with bronchospastic diseases. However, given their demonstrated benefit in such conditions as heart failure, myocardial infarction, cardiac arrhythmias and hypertension, cardioselective beta-blockers may be administered with caution to those who do not respond to or tolerate alternative treatment. The benefits generally outweigh the risks in patients with mild or moderate reactive airway disease that is well-controlled on inhaled corticosteroids and beta-2 adrenergic agonists, provided they have no prior history suggesting a predisposition to severe exacerbations. The dosage should start low, preferably in divided doses to avoid the higher plasma levels associated with longer dosing intervals, and titrated slowly according to therapeutic response and pulmonary function. Patients should be advised to contact their physician if they experience worsening of respiratory symptoms, which would warrant a reevaluation of the appropriateness of beta-blocker therapy. Cardioselective beta-blockers should be used with extreme caution, if at all, in patients prone to frequent exacerbations of their respiratory disease.
metoprolol ↔ formoterol
Applies to: metoprolol, Symbicort (budesonide/formoterol)
GENERALLY AVOID: Although cardioselective beta-blockers do not generally inhibit the bronchodilating effect of beta-2 adrenergic agonists, they may worsen pulmonary function in patients with asthma or other obstructive airway diseases. Cardioselective beta-blockers can occasionally precipitate acute bronchospasm in these patients, despite relative selectivity for beta-1 receptors in cardiac tissues. Presumably, beta-1 selectivity is dose-dependent and may be lost given a sufficient dose of the beta-blocker in susceptible patients. Other mechanisms may also be involved in bronchoconstriction that are unrelated to beta-2 blockade--for example, their effects on cholinergic M2 receptors and alpha-1 adrenoreceptors. Numerous single- and multiple-dose studies have been conducted in asthmatic and COPD patients with various cardioselective beta-blockers, including acebutolol, atenolol, bisoprolol, celiprolol, metoprolol, and nebivolol. Some reported no significant effects on pulmonary function or bronchodilator response to beta-2 adrenergic agonists, while others reported some negative effects on pulmonary function and/or airway hyperresponsiveness. Overall, a meta-analysis of more than two dozen studies found that use of cardioselective beta-blockers in patients with mild to moderate reversible airway disease produced no adverse respiratory effects or decreased responsiveness to beta-2 agonists in the short term. A meta-analysis of 19 studies conducted in patients with COPD by the same group of investigators reported similar results. However, little data exist regarding their safety during chronic use or use in patients with severe respiratory disease. There have been reports of worsening asthma and bronchospasm in patients receiving cardioselective beta-blockers including betaxolol (both systemic and ophthalmic) and esmolol. Several studies have suggested enhanced bronchosparing effects of celiprolol over other cardioselective beta-blockers due to its partial beta-2 agonistic and alpha-2 blocking activities. However, one study found no difference between celiprolol and nebivolol. A few studies also suggested a lower degree of beta-1 selectivity for acebutolol compared to other cardioselective beta-blockers. The clinical significance is unknown. MANAGEMENT: Beta-blockers, including those with relative cardioselectivity, should generally be avoided in patients with bronchospastic diseases. However, given their demonstrated benefit in such conditions as heart failure, myocardial infarction, cardiac arrhythmias and hypertension, cardioselective beta-blockers may be administered with caution to those who do not respond to or tolerate alternative treatment. The benefits generally outweigh the risks in patients with mild or moderate reactive airway disease that is well-controlled on inhaled corticosteroids and beta-2 adrenergic agonists, provided they have no prior history suggesting a predisposition to severe exacerbations. The dosage should start low, preferably in divided doses to avoid the higher plasma levels associated with longer dosing intervals, and titrated slowly according to therapeutic response and pulmonary function. Patients should be advised to contact their physician if they experience worsening of respiratory symptoms, which would warrant a reevaluation of the appropriateness of beta-blocker therapy. Cardioselective beta-blockers should be used with extreme caution, if at all, in patients prone to frequent exacerbations of their respiratory disease.
metoprolol ↔ lorazepam
Applies to: metoprolol, lorazepam
The pharmacologic effects of some benzodiazepines may be increased by some beta-blockers. Propranolol and metoprolol may inhibit the hepatic metabolism of diazepam and other mechanisms may also be involved. Most changes have been clinically insignificant; however, increased reaction times and/or decreased kinetic visual acuity have been reported with some combinations. Observation for altered benzodiazepine effects is recommended if these drugs must be used together. Patients should be warned against driving or operating hazardous machinery.
metoclopramide ↔ morphine
Applies to: metoclopramide, Roxanol (morphine)
Concomitant administration of metoclopramide and sustained-release morphine may decrease the time required to achieve peak morphine serum concentrations. In the acute clinical setting, this effect may be accompanied by an increased level of sedation and earlier onset. In patients being treated chronically, the interaction does not appear to have clinical significance.
diphenhydramine ↔ ipratropium
Applies to: diphenhydramine, Combivent (albuterol/ipratropium)
Theoretically, the potential exists for additive anticholinergic effects such as mydriasis, blurred vision, heat intolerance, fever, dry mouth, tachycardia, urinary retention, and constipation when ipratropium, oxitropium or tiotropium is used with each other or other agents with anticholinergic properties (e.g., antihistamines, antispasmodics, neuroleptics, phenothiazines, skeletal muscle relaxants, tricyclic antidepressants, class IA antiarrhythmics especially disopyramide). However, due to the poor systemic absorption of ipratropium, oxitropium, and tiotropium when administered locally, the interaction would be unlikely at regularly recommended dosages.
ipratropium ↔ cyclobenzaprine
Applies to: Combivent (albuterol/ipratropium), Flexeril (cyclobenzaprine)
Theoretically, the potential exists for additive anticholinergic effects such as mydriasis, blurred vision, heat intolerance, fever, dry mouth, tachycardia, urinary retention, and constipation when ipratropium, oxitropium or tiotropium is used with each other or other agents with anticholinergic properties (e.g., antihistamines, antispasmodics, neuroleptics, phenothiazines, skeletal muscle relaxants, tricyclic antidepressants, class IA antiarrhythmics especially disopyramide). However, due to the poor systemic absorption of ipratropium, oxitropium, and tiotropium when administered locally, the interaction would be unlikely at regularly recommended dosages.
metoprolol ↔ escitalopram
Applies to: metoprolol, Lexapro (escitalopram)
Escitalopram may increase the plasma concentrations of metoprolol. Administration of 20 mg/day escitalopram for 21 days resulted in a 50% increase of the maximum plasma concentration and an 82% increase of the AUC of metoprolol (single 100 mg dose); however, no clinically significant effects on blood pressure or heart rate occurred. The mechanism may be related to inhibition of CYP450 2D6 metabolism. Increased levels may decrease beta blocker cardioselectivity. It may be advisable to monitor patients for increased pharmacological effects of metoprolol.
No other interactions were found between your selected drugs.Note: this does not necessarily mean no interactions exist. ALWAYS consult with your doctor or pharmacist.
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Interactions between your selected drugs and food
morphine ↔ food
Applies to: Roxanol (morphine)
GENERALLY AVOID: The central nervous system-depressant effects of morphine and alcohol may be additive. The combination may result in additive CNS-depression and impairment of judgment, thinking, and psychomotor skills. In more severe cases, respiratory depression, hypotension, profound sedation, and coma can occur.GENERALLY AVOID: Consumption of alcohol while taking some sustained-release formulations of morphine may cause rapid release of the drug, resulting in high systemic levels of morphine that may be potentially lethal. Alcohol apparently can disrupt the release mechanism of some sustained-release formulations. The interaction was observed in in vitro studies using a 24-hour morphine formulation (Avinza 30 mg capsule, available in the U.S. from Ligand Pharmaceuticals). When the capsule was mixed with 900 mL of buffer solutions containing ethanol 20% and 40%, the dose of morphine that was released was alcohol concentration-dependent, leading to a more rapid release of morphine. Although the clinical relevance of this finding is unknown, 'dose-dumping' into the bloodstream is conceivable.MANAGEMENT: Until more information is available, patients taking sustained-release formulations of morphine should not consume alcohol or use medications that contain alcohol. In general, potent narcotics such as morphine should not be combined with alcohol.
metoprolol ↔ food
Applies to: metoprolol
ADJUST DOSING INTERVAL: The bioavailability of metoprolol may be enhanced by food. MANAGEMENT: Patients may be instructed to take metoprolol at the same time each day, preferably with or immediately following meals.
zolpidem ↔ food
Applies to: Ambien (zolpidem)
ADJUST DOSING INTERVAL: Administration of zolpidem with food may delay the onset of hypnotic effects. In 30 healthy subjects, administration of zolpidem 20 minutes after a meal resulted in decreased mean peak plasma drug concentration (Cmax) and area under the concentration-time curve (AUC) by 25% and 15%, respectively, compared to fasting. The time to reach peak plasma drug concentration (Tmax) was prolonged by 60%, from 1.4 to 2.2 hours.MANAGEMENT: For faster sleep onset, zolpidem should not be administered with or immediately after a meal.
budesonide ↔ food
Applies to: Symbicort (budesonide/formoterol)
GENERALLY AVOID: Grapefruit juice may increase the plasma concentrations and systemic effects of orally administered budesonide. The proposed mechanism is inhibition of CYP450 3A4-mediated first-pass metabolism in the gut wall by certain compounds present in grapefruits. According to the manufacturer, the systemic exposure of oral budesonide approximately doubles after extensive intake of grapefruit juice.MANAGEMENT: Patients receiving budesonide should avoid the regular consumption of grapefruits and grapefruit juice to prevent undue increases in plasma budesonide levels and systemic effects.
multivitamin with iron ↔ food
Applies to: Dialyvite (multivitamin with iron)
Food taken in conjunction with oral iron supplements may reduce the bioavailability of the iron. However, in many patients intolerable gastrointestinal side effects occur necessitating administration with food. Some studies suggest administration of iron with ascorbic acid may enhance bioavailability. Ideally, iron products should be taken on an empty stomach, but if this is not possible, administer with meals and monitor the patient more closely for a subtherapeutic effect.
See Read more: http://www.drugs.com/interactions-check.php?drug_list=704-0,896-0,940-0,1488-0,1612-0,1615-0,1750-0,2221-0,2228-0,2333-1544,784-405,2128-3117,679-335,110-813,1663-6037,758-386,1349-805,1344-803,1013-565,71-8473,1937-2171,462-9177,1656-1833,2054-1344,432-2530,1388-1744,1752-1120#ixzz0u4lYmDns
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