OTC

Tagamet HB 200cimetidine

Entire Monograph

Uses

[ cimetidine ]H2-antagonist for relieving heartburn

Dosing

>12 yo

[ oral tablet ]Dose: 1 tab PO prn; Max: 2 tabs/24h

renal dosing

[ adjust dose amount ]CrCl 10-50: decr. dose 50%; CrCl <10: decr. dose 75%; HD/PD: no supplement

hepatic dosing

[ not defined ]

Formulations

oral tablet

[active ingredients per tab]cimetidine 200 mg

Contraindications/Cautions

hypersens. to drug/class/compon. caution if renal impairment

caution if hepatic impairment

caution in elderly or debilitated pts

caution if chronic pulmonary dz

caution if diabetes mellitus

caution if immunocompromised

Drug Interactions

Contraindicated

cisapridecontraindicated: combo may incr. risk of QT prolongation, cardiac arrhythmias (hepatic metab. inhibited)

dofetilidecontraindicated: combo may incr. dofetilide levels, risk of QT prolongation, cardiac arrhythmias (renal excretion decreased, hepatic metab. inhibited)

thioridazinecontraindicated: combo may incr. risk of QT prolongation, cardiac arrhythmias (hepatic metab. inhibited)

Avoid/Use Alternative

atazanaviravoid combo in pts <40 kg; for all other pts, see atazanavir pkg insert for specific recommendations: combo may decr. atazanavir levels, efficacy (absorption decreased at higher gastric pH)

benzodiazepines, partial CYP3A4 substratesuse alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)[benzodiazepines, partial CYP3A4 substrates: chlordiazepoxide, clonazepam, clorazepate, diazepam, diazepam rectal, flurazepam]

beta blocker/thiazide combosuse alternative or non-hepatically metabolized beta blocker (e.g. atenolol, nadolol): combo may incr. risk of bradycardia, hypotension (hepatic metab. inhibited)[beta blocker/thiazide combos: atenolol/chlorthalidone, bisoprolol/hydrochlorothiazide, metoprolol succinate/hydrochlorothiazide, metoprolol tartrate/hydrochlorothiazide, nadolol/bendroflumethiazide, propranolol/hydrochlorothiazide]

beta blockers, systemicuse alternative or non-hepatically metabolized beta blocker (e.g. atenolol, nadolol): combo may incr. risk of bradycardia, hypotension (hepatic metab. inhibited)[beta blockers, systemic: acebutolol, atenolol, betaxolol, bisoprolol, carvedilol, esmolol,

labetalol, metoprolol succinate, metoprolol tartrate, nadolol, nebivolol, penbutolol, pindolol, propranolol, timolol]

calcium channel blockers, othersuse alternative: combo may incr. risk of bradycardia, hypotension (hepatic metab. inhibited)[calcium channel blockers, others: diltiazem, trandolapril/verapamil, verapamil]

cefditorenuse alternative: combo may decr. cefditoren levels, efficacy (absorption decreased)

cefpodoximeuse alternative: combo may decr. cefpodoxime levels, efficacy (absorption decreased)

cefuroximeuse alternative: combo may decr. oral cefuroxime levels, efficacy (absorption decreased at higher gastric pH)[cefuroxime: cefuroxime axetil, cefuroxime sodium]

clopidogrelavoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite)

dasatinibuse alternative: combo may decr. dasatinib levels, efficacy (absorption decreased at higher gastric pH)

delavirdineuse alternative: combo may decr. delavirdine efficacy (absorption decreased)

epirubicinavoid combo: combo may incr. epirubicin levels, risk of toxicity (mechanism unknown)

erlotinibavoid combo or give erlotinib 10h after previous H2 receptor blocker dose and 2h before next dose: combo may decr. erlotinib levels (absorption decreased at higher gastric pH)

ezetimibe/simvastatinuse alternative: combo may incr. simvastatin levels, risk of myopathy, rhabdomyolysis (hepatic metab. inhibited)

iron salts, oraluse alternative or give iron 1h before: combo may decr. iron efficacy (absorption decreased at higher gastric pH)[iron salts, oral: ferrous gluconate, ferrous sulfate]

itraconazoleuse alternative or admin. itraconazole w/ cola to incr. acidity: combo may decr. antifungal efficacy (absorption decreased, requires acid pH)

ketoconazoleuse alternative or admin. ketoconazole w/ cola to incr. acidity: combo may decr. antifungal efficacy (absorption decreased, requires acid pH)

linagliptin/metforminuse alternative: combo may incr. metformin levels, risk of adverse effects including lactic acidosis (renal excretion decr. by competition for active tubular transport)

mesalamineavoid combo; does not apply to Pentasa formulation: combo may decr. mesalamine efficacy (premature dissolution occurs if gastric pH increased)

metformin/sulfonylurea combosuse alternative: combo may incr. metformin levels, risk of adverse effects including lactic acidosis (renal excretion decreased)[metformin/sulfonylurea combos: glipizide/metformin, glyburide/metformin]

metforminsuse alternative: combo may incr. metformin levels, risk of adverse effects including lactic acidosis (renal excretion decreased)[metformins: metformin, pioglitazone/metformin, repaglinide/metformin, rosiglitazone/metformin]

naproxenavoid combo w/ enteric-coated naproxen: combo may result in premature dissolution of enteric coating, incr. GI adverse effects (gastric pH increased)[naproxen: naproxen, naproxen sodium]

nevirapineuse alternative: combo may incr. nevirapine levels (hepatic metab. inhibited)

posaconazoleweigh risk/benefit: combo may decr. posaconazole levels, efficacy (mechanism unknown, absorption possibly altered)

quinidineuse alternative: combo may incr. quinidine levels, risk of toxicity (hepatic metab. inhibited)[quinidine: quinidine gluconate, quinidine sulfate]

saxagliptin/metforminuse alternative: combo may incr. metformin levels, risk of adverse effects including lactic acidosis (renal excretion decr. by competition for active tubular transport)

sirolimususe alternative or monitor levels: combo may incr. sirolimus levels, risk of toxicity (gastrointestinal, hepatic metab. inhibited)

sitagliptin/metforminuse alternative: combo may incr. cimetidine and meformin levels, risk of adverse effects including lactic acidosis (renal excretion decr. by competition for active tubular transport; renal excretion decr. by nephrotoxic agents)

tacrineuse alternative H2 blocker or monitor for adverse effects: combo may incr. tacrine levels, risk of cholinergic adverse effects (hepatic metab. inhibited)

terbinafineuse alternative: combo may incr. terbinafine levels, risk of toxicity (hepatic metab. inhibited, clearance decreased 33%)

tizanidineavoid combo or use alternative: combo may incr. tizanidine levels, incr. risk of hypotension, bradycardia, psychomotor impairment, other adverse effects (hepatic metab. inhibited)

tricyclic antidepressantsuse alternative or decr. max TCA dose 50%: combo may incr. TCA levels, risk of adverse effects (hepatic metab. inhibited)[tricyclic antidepressants: amitriptyline, amoxapine, chlordiazepoxide/amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, perphenazine/amitriptyline, protriptyline, trimipramine]

zolmitriptanuse alternative H2 blocker or monitor for adverse effects: combo may prolong zolmitriptan effect, incr. levels, risk of toxicity (hepatic metab. inhibited)[zolmitriptan: zolmitriptan, zolmitriptan nasal]

Monitor/Modify Tx

acetaminophen/aspirin/caffeinemonitor levels, decr. caffeine dose or limit caffeine consumption: combo may incr. caffeine levels, risk of cardiovascular and CNS stimulatory effects, toxicity (hepatic metab. inhibited)

acetaminophen/caffeinemonitor levels, decr. caffeine dose or limit caffeine consumption: combo may incr. caffeine levels, risk of cardiovascular and CNS stimulatory effects, toxicity (hepatic metab. inhibited)

acetaminophen/caffeine/CNS depressant combosdecr. caffeine dose or limit caffeine consumption: combo may incr. caffeine levels, risk of cardiovascular and CNS stimulatory effects, toxicity (hepatic metab. inhibited)[acetaminophen/caffeine/CNS depressant combos: acetaminophen/caffeine/dihydrocodeine, butalbital/acetaminophen/caffeine, butalbital/acetaminophen/caffeine/codeine]

acyclovircaution advised, decr. acyclovir dose only if renal impairment: combo may incr. acyclovir levels (renal excretion decreased)

alfentanilcaution advised, consider lower alfentanil doses: combo may incr. alfentanil levels, risk of CNS and resp. depression, delayed recovery from alfentanil anesthesia (hepatic metab. inhibited)

aripiprazoleconsider decr. aripiprazole dose 50%: combo may incr. aripiprazole levels (hepatic metab. inhibited)

aspirin/caffeinemonitor levels, decr. caffeine dose or limit caffeine consumption: combo may incr. caffeine levels, risk of cardiovascular and CNS stimulatory effects, toxicity (hepatic metab. inhibited)

atomoxetineconsider maintaining atomoxetine start dose x4wk, then incr. to target dose only if no response and well-tolerated: combo may incr. atomoxetine levels, risk of adverse effects (hepatic metab. inhibited)

bosutinibseparate admin. by >2h: combo may decr. bosutinib levels, efficacy (absorption decreased at higher gastric pH)

caffeinemonitor levels, decr. caffeine dose or limit caffeine consumption: combo may incr. caffeine levels, risk of cardiovascular and CNS stimulatory effects, toxicity (hepatic metab. inhibited)[caffeine: caffeine, caffeine citrate, caffeine/sodium benzoate]

carbamazepinemonitor levels: combo may incr. carbamazepine levels, risk of toxicity (hepatic metab. inhibited)

carmustinemonitor CBC: combo may incr. risk of myelosuppression (mechanism unknown)

citaloprammax citalopram dose 20 mg/day: combo may incr. citalopram levels, risk of QT prolongation, cardiac arrhythmias, serotonin syndrome, other adverse effects (hepatic metab. inhibited)

clobazamcaution advised, consider lower clobazam dose: combo may incr. clobazam and active metabolite levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

CNS depressant/aspirin/caffeine combosmonitor levels, decr. caffeine dose or limit caffeine consumption: combo may incr. caffeine levels, risk of cardiovascular and CNS stimulatory effects, toxicity (hepatic metab. inhibited)[CNS depressant/aspirin/caffeine combos: butalbital/aspirin/caffeine, butalbital/aspirin/caffeine/codeine, dihydrocodeine/aspirin/caffeine]

cyclosporinemonitor levels: combo may incr. cyclosporine levels, risk of nephrotoxicity, other adverse effects (hepatic metab. inhibited; mechanism unknown)[cyclosporine: cyclosporine modified, cyclosporine non-modified]

emtricitabine/rilpivirine/tenofovir disoproxilgive H2 blockers 12h before or 4h after emtricitabine/rilpivirine/tenofovir: combo may decr. rilpivirine levels, efficacy; may incr. levels of tenofovir and cimetidine (absorption decreased at higher pH; renal excretion decr. by competition for active tubular transport)

felodipinemonitor BP: combo may incr. dihydropyridine levels, risk of hypotension, other calcium-channel blocker effects (hepatic metab. inhibited)

fentanylconsider lower fentanyl doses; monitor resp. rate, adverse effects: combo may incr. fentanyl levels, risk of prolonged/severe CNS and respiratory depression, other adverse effects; may delay recovery from fentanyl anesthesia (hepatic metab. inhibited)[fentanyl: fentanyl, fentanyl nasal, fentanyl transdermal, fentanyl transmucosal]

isradipinemonitor BP: combo may incr. dihydropyridine levels, risk of hypotension, other calcium-channel blocker effects (hepatic metab. inhibited)

nicardipinemonitor BP: combo may incr. dihydropyridine levels, risk of hypotension, other calcium-channel blocker effects (hepatic metab. inhibited)

nifedipinemonitor BP: combo may incr. dihydropyridine levels, risk of hypotension, other calcium-channel blocker effects (hepatic metab. inhibited)

nilotinibseparate admin. by at least several hours: combo may decr. nilotinib levels, efficacy (absorption decreased at higher pH)

nimodipinemonitor BP: combo may incr. dihydropyridine levels, risk of hypotension, other calcium-channel blocker effects (hepatic metab. inhibited)

nisoldipinemonitor BP: combo may incr. dihydropyridine levels, risk of hypotension, other calcium-channel blocker effects (hepatic metab. inhibited)

pemetrexedcaution advised, monitor toxicity: combo may incr. levels of both drugs (renal excretion decr. by competition for active tubular transport)

peppermint oilseparate admin. by at least 2h w/ enteric-coated peppermint oil: combo may decr. peppermint oil efficacy, increase adverse effects (premature dissolution of enteric-coated peppermint oil)[peppermint oil: aetheroleum, balm mint, black peppermint, brandy mint, curled mint, feuilles de menthe, Mentha piperita, Menthe poivree, Our Lady's mint, peppermint oil (Mentha x piperita), white peppermint]

phenytoinsmonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)[phenytoins: fosphenytoin, phenytoin]

procainamidemonitor levels: combo may incr. procainamide/NAPA levels, risk of toxicity (renal excretion decreased)

rilpivirinegive H2 blockers 12h before or 4h after rilpivirine: combo may decr. rilpivirine levels, efficacy (absorption decreased at higher gastric pH)

sufentanilcaution advised, consider lower sufentanil doses: combo may incr. risk of CNS and resp. depression, delayed recovery from sufentanil anesthesia (hepatic metab. inhibited)

tacrolimusmonitor levels: combo may incr. tacrolimus levels, risk of toxicity (hepatic metab. inhibited)

theophyllinesmonitor levels: combo may incr. theophylline levels, risk of toxicity (hepatic metab. inhibited)[theophyllines: aminophylline, theophylline]

valacyclovircaution advised, decr. valacyclovir dose only if renal impairment: combo may incr. valacyclovir levels (renal excretion decreased)

valproic acid derivativesmonitor levels: combo may incr. valproic acid levels, risk of toxicity (hepatic metab.

inhibited)[valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid]

vismodegibcaution advised, consider D/C H2 blocker: combo may decr. vismodegib levels, efficacy (absorption decr. at higher gastric pH)

warfarinmonitor INR: combo may incr. INR, risk of bleeding (hepatic metab. inhibited)

zaleplonadjust zaleplon dose to 5 mg qhs: combo may incr. zaleplon levels, risk of adverse effects (hepatic metab. inhibited)

Therapeutic Advantage

digestive enzymesmay be used for therapeutic advantage if severe pancreatic insufficiency: combo may incr. efficacy of enteric-coated digestive enzyme products (gastric pH increased, prevents inactivation of enzyme after release from enteric-coated products)[digestive enzymes: pancrelipase]

Caution Advised

albendazolecaution advised: combo may incr. albendazole levels, risk of toxicity (mechanism unknown)

alendronate/cholecalciferolcaution advised: combo may decr. cholecalciferol efficacy (hepatic metab. inhibited, decr. conversion to activated vitamin D)

alfuzosincaution advised: combo may incr. alfuzosin levels, risk of adverse effects (hepatic metab. inhibited)

alprazolamcaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

amiodaronecaution advised: combo may incr. amiodarone levels, risk of toxicity (hepatic metab. possibly inhibited)

atovaquone/proguanilcaution advised: combo may decr. proguanil active metabolite levels, efficacy (hepatic metab. inhibited, decr. conversion to active metabolite)

azelastine nasalcaution advised: combo may incr. azelastine levels, risk of CNS depression, psychomotor impairment (hepatic metab. possibly inhibited)[azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal]

bupropioncaution advised: combo may incr. bupropion adverse effects (hepatic metab. inhibited)[bupropion: bupropion hydrobromide, bupropion hydrochloride]

buspironecaution advised: combo may incr. buspirone levels, risk of adverse effects (hepatic metab. inhibited)

capsicumcaution advised: combo may decr. H2 blocker efficacy (antagonistic effects, stomach acid possibly incr. by capsicum)[capsicum: African chilies, capsaicin, capsicum (Capsicum annuum), Capsicum annuum, cayenne, chili pepper, green chili pepper, Louisiana long pepper, Mexican chilies, paprika, pimento, red pepper, tabasco pepper]

chloroquine phosphatecaution advised: combo may incr. chloroquine levels (hepatic metab. inhibited)

clozapinecaution advised: combo may incr. clozapine levels, risk of toxicity (hepatic metab. inhibited)

crizotinibcaution advised: combo may decr. crizotinib levels, efficacy (absorption decreased at higher gastric pH)

dolasetroncaution advised: combo may incr. dolasetron levels (hepatic metab. inhibited)

duloxetinecaution advised: combo may incr. duloxetine levels (hepatic metab. inhibited)

dutasteride/tamsulosincaution advised: combo may incr. tamsulosin levels, risk of adverse effects (hepatic metab. inhibited)

efavirenz/emtricitabine/tenofovir disoproxilcaution advised: combo may incr. levels of tenofovir and cimetidine (renal excretion decr. by competition for active tubular transport)

emtricitabine/tenofovir disoproxilcaution advised: combo may incr. levels of tenofovir and cimetidine (renal excretion decr. by competition for active tubular transport)

[emtricitabine/tenofovir disoproxil: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil, emtricitabine/tenofovir disoproxil]

entecavircaution advised: combo may incr. levels of both drugs (renal excretion decr. by competition for active tubular transport)

escitalopramcaution advised: combo may incr. escitalopram levels, risk of adverse effects (hepatic metab. inhibited)

ethanolcaution advised: combo may incr. blood alcohol levels, risk of CNS depression, psychomotor impairment (absorption increased, gastric alcohol dehydrogenase inhibited)

etravirinecaution advised: combo may incr. etravirine levels, risk of adverse effects (hepatic metab. inhibited)

flecainidecaution advised: combo may incr. flecainide levels, risk of cardiac arrhythmias (hepatic metab. inhibited)

fluvastatincaution advised: combo may incr. fluvastatin levels, risk of myopathy, rhabdomyolysis (mechanism unknown, absorption possibly altered)

fosamprenavircaution advised: combo may decr. amprenavir levels, efficacy (mechanism unknown)

gefitinibcaution advised: combo may decr. gefitinib levels, efficacy (absorption decreased at higher gastric pH)

gingercaution advised: combo may decr. H2 blocker efficacy (antagonistic effects)[ginger: African ginger, black ginger, cochin ginger, ginger (Zingiber officinale), Imber, Jamaica ginger, race ginger, rhizoma zingerberis, sheng jiang, Shokyo, Zingiber officinale, Zingiberis rhizoma]

goldensealcaution advised: combo may decr. H2 blocker efficacy (antagonistic effects, stomach acid possibly incr. by goldenseal)[goldenseal: berberine, eye balm, eye root, goldenseal (Hydrastis canadensis), ground raspberry, Hydrastis canadensis, Indian plant, jaundice root, orange root, wild curcuma, yellow root]

green teacaution advised: combo may incr. caffeine levels, caffeine-related adverse effects due to

caffeine in green tea (caffeine clearance decreased)[green tea: Camellia sinensis, Camellia thea, Chinese tea, green tea (Camellia sinensis), green tea extract, GTE, Japanese tea, Matsu-cha tea, Theaceae, theifers]

guaranacaution advised: combo may incr. caffeine levels, caffeine-related adverse effects due to caffeine in guarana (caffeine clearance decreased)[guarana: Brazilian cocoa, guarana (Paullinia cupana), guarana gum, guarana paste, guaranine, Paullinia cupana, Uabano, Uaranzeiro, zoom]

lidocainecaution advised w/ systemic lidocaine: combo may incr. lidocaine levels, risk of adverse effects (mechanism unknown, hepatic metab. possibly inhibited)

memantinecaution advised: combo may incr. levels of both drugs (renal excretion decr. by competition for active tubular transport mechanism)

meperidinecaution advised: combo may incr. meperidine levels, risk of respiratory depression, other adverse effects (hepatic metab. inhibited)

mepivacainecaution advised: combo may incr. risk of anesthetic toxicity (clearance decreased)

methylphenidatecaution advised w/ Ritalin LA only: combo may alter delayed-release properties of Ritalin LA; result in premature dissolution of enteric coated beads (gastric pH increased)[methylphenidate: dexmethylphenidate, methylphenidate, methylphenidate transdermal]

midazolamcaution advised w/ oral midazolam: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

midodrinecaution advised: combo may incr. levels of both drugs (renal excretion decr. by competition for active tubular transport mechanism)

mycophenolic acidcaution advised: combo may incr. levels, risk of toxicity of both drugs (renal excretion decr. by competition for active tubular transport)[mycophenolic acid: mycophenolate mofetil, mycophenolic acid]

olanzapinecaution advised: combo may incr. olanzapine levels, risk of toxicity (hepatic metab. inhibited)

olanzapine/fluoxetinecaution advised: combo may incr. olanzapine levels, risk of toxicity (hepatic metab. inhibited)

paroxetinecaution advised: combo may incr. paroxetine levels, risk of adverse effects (hepatic metab. inhibited)

pentamidinecaution advised: combo may incr. pentamidine levels, risk of adverse effects, incl. QT prolongation, cardiac arrhythmias (hepatic metab. inhibited)

pimozidecaution advised: combo may incr. pimozide levels, risk of QT prolongation, cardiac arrhythmias (hepatic metab. inhibited)

pramipexolecaution advised: combo may incr. pramipexole levels, risk of adverse effects (renal excretion inhibited; renal excretion decr. by competition for active tubular transport)

propafenonecaution advised: combo may incr. propafenone levels, risk of adverse effects (hepatic metab. inhibited)

quetiapinecaution advised: combo may incr. quetiapine levels, risk of toxicity (hepatic metab. inhibited)

ramelteoncaution advised: combo may incr. ramelteon levels (hepatic metab. inhibited)

red yeastcaution advised, red yeast contains lovastatin: combo may incr. lovastatin levels, risk of adverse effects (hepatic metab. inhibited)[red yeast: Angkak, beni-koju, hong qu, Monascus purpureus, red koji, red leaven, red yeast (Monascus purpureus), red yeast rice, RYR, xue zhi kang, zhi tai]

riluzolecaution advised: combo may incr. riluzole levels, risk of adverse effects (hepatic metab. inhibited)

roflumilastcaution advised: combo may incr. roflumilast levels, risk of adverse effects (hepatic metab. inhibited)

sertralinecaution advised: combo may incr. sertraline levels, risk of adverse effects (hepatic metab. inhibited)

sildenafilcaution advised: combo may incr. sildenafil levels, risk of adverse effects (hepatic metab. inhibited)

sitagliptincaution advised: combo may incr. cimetidine levels, risk of adverse effects (renal excretion decr. by competition for active tubular transport mechanism)

sitagliptin/simvastatincaution advised: combo may incr. levels of cimetidine and sitagliptin, risk of adverse effects (renal excretion decr. by competition for active tubular transport mechanism)

tamoxifencaution advised: combo may decr. active tamoxifen metabolite levels, efficacy (hepatic metab. inhibited)

tamsulosincaution advised: combo may incr. tamsulosin levels, risk of adverse effects (hepatic metab. inhibited)

tenofovir disoproxilcaution advised: combo may incr. levels of both drugs (renal excretion decr. by competition for active tubular transport)

tetrabenazinecaution advised: combo may incr. tetrabenazine active metabolite levels, risk of adverse effects (hepatic metab. inhibited)

tramadolcaution advised: combo may incr. tramadol levels, risk of seizures, other adverse effects; may decr. active metabolite levels, analgesic efficacy (hepatic metab. inhibited, decr. conversion to active metabolite)

tramadol/acetaminophencaution advised: combo may incr. tramadol levels, risk of seizures, other adverse effects; may decr. active metabolite levels, analgesic efficacy (hepatic metab. inhibited, decr. conversion to active metabolite)

triazolamcaution advised: combo may incr. triazolam levels, risk of CNS depression, psychomotor impairment (absorption increased at higher gastric pH)

venlafaxinecaution advised: combo may incr. venlafaxine levels, risk of QT prolongation, cardiac arrhythmias, other adverse effects (hepatic metab. inhibited)

Adverse Reactions

Serious Reactions

neutropenia thrombocytopenia

agranulocytosis

aplastic anemia

pneumonia

depression

psychosis

hallucinations

anaphylactic/anaphylactoid rxns

pancreatitis

interstitial nephritis

bradycardia

tachycardia

AV block

skin rxns, severe

Common Reactions

headache diarrhea

dizziness

gynecomastia

nausea

vomiting

confusion

agitation

drowsiness

rash

ALT, AST elevated

Safety/Pharmacology

Pregnancy: B (Animal studies show no risk or adverse fetal effects but controlled human 1st trimester studies not avail/do not confirm; no evidence of 2nd or 3rd trimester risk; fetal harm possible but unlikely; see pkg insert drug-specific recs)

Lactation: Probably Safe (Limited information in animals and/or humans demonstrates no risk/minimal risk of adverse effects to infant/breast milk production; caution advised)

Metabolism: liver; CYP450: 1A2 (weak), 2C19, 2D6 (weak) inhibitor

Excretion: urine primarily (48% unchanged), feces; Half-life: 2h

Subclass: H2 Blockers

Mechanism of Action: selectively antagonizes histamine H2 receptors

Manufacturer/Pricing

Manufacturer: Prestige Brands Holdings, Inc.

DEA/FDA: OTC Available over-the-counter without prescription

Approximate Retail Price

from www.drugstore.com

This information is currently not available for this OTC.

Alternatives

Search for Alternative Products by:

Other OTCs w/ Same Active Ingredient(s)No Other OTCs with the same active ingredients

Same SubclassH2 Blockers

Related SubclassesAntacidsH. pylor

Drug

Toradolketorolac

Entire Monograph

Black Box Warnings

Brand Discontinued in US select or search generic name for alternatives

Adult Dosing

Dosage forms:  --

Brand Discontinued in US

[see generic]

Peds Dosing

Dosage forms:  --

Brand Discontinued in US

[see generic]

Contraindications/Cautions

Brand Discontinued in US

Drug Interactions

Contraindicated

acetaminophen/aspirincontraindicated w/ ketorolac; avoid aspirin >325 mg/day and monitor renal fxn w/ other NSAIDs: combo of NSAIDs and aspirin may incr. risk of GI bleeding, adverse effects; combo w/ acetaminophen may incr. risk of nephrotoxicity (additive effects, possible competition for platelet binding sites; mechanism unknown)

acetaminophen/aspirin/caffeinecontraindicated w/ ketorolac; avoid aspirin >325 mg/day and monitor renal fxn w/ other NSAIDs: combo of NSAIDs and aspirin may incr. risk of GI bleeding, adverse effects; combo w/ acetaminophen may incr. risk of nephrotoxicity (additive effects, possible competition for platelet binding sites; mechanism unknown)

aspirinaspirin use contraindicated w/ ketorolac; avoid aspirin >325 mg/day w/ other NSAIDs; caution advised w/ low-dose aspirin + NSAIDs: combo may incr. risk of GI bleeding, adverse effects; ibuprofen may inhibit cardioprotective effect of low-dose aspirin (additive effects; possible competition for platelet binding sites)

aspirin/caffeineaspirin use contraindicated w/ ketorolac; avoid aspirin >325 mg/day w/ other NSAIDs: combo w/ aspirin may incr. risk of GI bleeding, adverse effects (additive effects, possible competition for platelet binding sites)

aspirin/calcium carbonateaspirin use contraindicated w/ ketorolac: combo may incr. risk of GI bleeding, adverse effects (additive effects)

aspirin/chlorpheniramine/dextromethorphanaspirin use contraindicated w/ ketorolac; avoid aspirin >325 mg/day w/ other NSAIDs: combo of NSAIDs and aspirin may incr. risk of GI bleeding, adverse effects (additive effects)

aspirin/chlorpheniramine/dextromethorphan/phenylephrineaspirin use contraindicated w/ ketorolac; avoid aspirin >325 mg/day w/ other NSAIDs:

combo of NSAIDs and aspirin may incr. risk of GI bleeding, adverse effects (additive effects)

aspirin/chlorpheniramine/phenylephrineaspirin use contraindicated w/ ketorolac; avoid aspirin >325 mg/day w/ other NSAIDs: combo of NSAIDs and aspirin may incr. risk of GI bleeding, adverse effects (additive effects)

aspirin/diphenhydramineaspirin use contraindicated w/ ketorolac; avoid aspirin >325 mg/day w/ other NSAIDs: combo of NSAIDs and aspirin may incr. risk of GI bleeding, adverse effects (additive effects)

aspirin/dipyridamoleaspirin use contraindicated w/ ketorolac; avoid aspirin >325 mg/day w/ other NSAIDs; caution advised w/ low-dose aspirin + NSAIDs: combo may incr. risk of GI bleeding, adverse effects; ibuprofen may inhibit cardioprotective effect of low-dose aspirin (additive effects; possible competition for platelet binding sites)

aspirin/doxylamine/dextromethorphan/phenylephrineaspirin use contraindicated w/ ketorolac; avoid aspirin >325 mg/day w/ other NSAIDs: combo of NSAIDs and aspirin may incr. risk of GI bleeding, adverse effects (additive effects)

aspirin/phenylephrineaspirin use contraindicated w/ ketorolac; avoid aspirin >325 mg/day w/ other NSAIDs: combo of NSAIDs and aspirin may incr. risk of GI bleeding, adverse effects (additive effects)

carisoprodol/aspirinaspirin use contraindicated w/ ketorolac; avoid aspirin >325 mg/day w/ other NSAIDs; caution advised w/ low-dose aspirin + NSAIDs: combo w/ aspirin may incr. risk of GI bleeding, adverse effects (additive effects)

celecoxibcontraindicated for ketorolac; avoid combo w/ other NSAIDs: combo may incr. risk of GI bleeding, adverse effects (additive effects, duplicate tx)

cidofovircontraindicated, avoid combo during and for 7 days prior to cidofovir tx: combo may incr. risk of nephrotoxicity (overlapping toxicity, additive effects)

CNS depressant/aspirin/caffeine combosaspirin use contraindicated w/ ketorolac; avoid aspirin >325 mg/day w/ other NSAIDs; caution advised w/ low-dose aspirin + NSAIDs: combo w/ aspirin may incr. risk of GI bleeding, adverse effects (additive effects)[CNS depressant/aspirin/caffeine combos: butalbital/aspirin/caffeine, butalbital/aspirin/caffeine/codeine, dihydrocodeine/aspirin/caffeine]

opiate/aspirin combosaspirin use contraindicated w/ ketorolac; avoid aspirin >325 mg/day w/ other NSAIDs; caution advised w/ low-dose aspirin + NSAIDs: combo w/ aspirin may incr. risk of GI bleeding, adverse effects (additive effects)[opiate/aspirin combos: carisoprodol/aspirin/codeine, oxycodone/aspirin]

pentoxifyllinecontraindicated for ketorolac, caution advised w/ other NSAIDs: combo may incr. risk of bleeding (additive effects)

probenecidcontraindicated for ketorolac; avoid combo w/ other NSAIDs: combo may incr. NSAID adverse effects (renal excretion decreased)

Avoid/Use Alternative

beta blocker/thiazide combosmonitor BP, consider alternatives: combo may decr. antihypertensive, diuretic, and natriuretic efficacy (antagonistic effect due to NSAID-induced inhibition of renal prostaglandins, sodium and fluid retention)[beta blocker/thiazide combos: atenolol/chlorthalidone, bisoprolol/hydrochlorothiazide, metoprolol succinate/hydrochlorothiazide, metoprolol tartrate/hydrochlorothiazide, nadolol/bendroflumethiazide, propranolol/hydrochlorothiazide]

beta blockers, systemicmonitor BP, consider alternatives: combo may decr. antihypertensive efficacy (antagonistic effect due to NSAID-induced inhibition of renal prostaglandins, sodium and fluid retention)[beta blockers, systemic: acebutolol, atenolol, betaxolol, bisoprolol, carvedilol, esmolol, labetalol, metoprolol succinate, metoprolol tartrate, nadolol, nebivolol, penbutolol, pindolol, propranolol, timolol]

danshenavoid combo: combo may incr. risk of bleeding (additive antiplatelet effects)[danshen: ch'ih shen, danshen (Salvia miltiorrhiza), huang ken, pin-ma ts'ao, red sage, saliva root, Salvia miltiorrhiza Bunge, shu-wei ts'ao, tan-shen, tzu tan-ken]

diclofenac topicalavoid combo: combo may incr. risk of adverse effects (additive NSAID effects; up to 10% systemic absorption of diclofenac topical; minimal absorption w/ patch)[diclofenac topical: diclofenac epolamine topical, diclofenac topical]

drotrecogin alfaweigh risk/benefit if NSAIDs w/in 7 days prior to drotrecogin alfa: combo may incr. risk of bleeding (additive effects)

ethanolavoid or minimize alcohol use: combo may incr. risk of GI bleeding, gastritis (additive effects)

fondaparinuxweigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)

heparinsweigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[heparins: dalteparin, enoxaparin, heparin, tinzaparin]

hydrocodone/ibuprofenavoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased)

ibritumomab tiuxetanweigh risk/benefit, monitor platelets: combo may incr. risk of bleeding (additive effects, ibritumomab induces severe prolonged thrombocytopenia)

methotrexateavoid combo w/ high (anti-neoplastic) dose methotrexate, caution advised w/ low (anti-rheumatic) doses; monitor CBC, renal fxn: combo w/ high dose methotrexate may incr. methotrexate levels, risk of toxicity; interaction w/ low dose methotrexate not usually clinically significant (renal excretion decreased)

mycophenolic acidavoid combo; monitor renal fxn, BP: combo may incr. risk of GI bleeding, nephrotoxicity, HTN, edema, other adverse effects (additive/synergistic toxicity)[mycophenolic acid: mycophenolate mofetil, mycophenolic acid]

naproxen/esomeprazoleavoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased)

NSAID/chlorpheniramine/pseudoephedrine combosavoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased)[NSAID/chlorpheniramine/pseudoephedrine combos: ibuprofen/chlorpheniramine/pseudoephedrine]

NSAID/diphenhydramine combosavoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased)[NSAID/diphenhydramine combos: ibuprofen/diphenhydramine]

NSAID/phenylephrine combosavoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased)[NSAID/phenylephrine combos: ibuprofen/phenylephrine]

NSAID/pseudoephedrine combosavoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased)[NSAID/pseudoephedrine combos: ibuprofen/pseudoephedrine, naproxen sodium/pseudoephedrine]

NSAIDsavoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased)[NSAIDs: diclofenac potassium, diclofenac sodium, diclofenac/misoprostol, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, ibuprofen lysine, indomethacin, ketoprofen, ketorolac, ketorolac nasal, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, naproxen sodium, oxaprozin, piroxicam, sulindac, tolmetin]

oxycodone/ibuprofenavoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased)

pemetrexedavoid short-acting NSAID 2 days before until 2 days after pemetrexed dose in pts w/ CrCl <80; avoid long-acting NSAID 5 days before until 2 days after pemetrexed in all pts: combo may incr. pemetrexed levels, risk of bone marrow, renal and GI toxicity (renal excretion decr. by competition for active tubular transport)

pentosan polysulfate sodiumweigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)

sirolimusavoid combo; monitor renal fxn, BP, electrolytes: combo may incr. risk of nephrotoxicity, HTN, electrolyte abnormalities, edema, other adverse effects (additive/synergistic toxicity)

sumatriptan/naproxen sodiumavoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased)

tacrolimusavoid combo; monitor renal fxn, BP, electrolytes: combo may incr. risk of nephrotoxicity, HTN, electrolyte abnormalities, edema, other adverse effects (additive/synergistic toxicity)

tositumomab and iodine I 131 tositumomab weigh risk/benefit, monitor platelets: combo may incr. risk of bleeding (additive effects, tositumomab induces severe prolonged thrombocytopenia)

warfarinweigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)

Monitor/Modify Tx

ACE inhibitor/thiazide combosmonitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[ACE inhibitor/thiazide combos: benazepril/hydrochlorothiazide, captopril/hydrochlorothiazide, enalapril/hydrochlorothiazide, fosinopril/hydrochlorothiazide, lisinopril/hydrochlorothiazide, moexipril/hydrochlorothiazide, quinapril/hydrochlorothiazide]

ACE inhibitorsmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[ACE inhibitors: benazepril, captopril, enalapril, enalaprilat, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, trandolapril]

acetaminophen/caffeinemonitor renal fxn: combo w/ acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/caffeine/CNS depressant combosmonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)[acetaminophen/caffeine/CNS depressant combos: acetaminophen/caffeine/dihydrocodeine, butalbital/acetaminophen/caffeine, butalbital/acetaminophen/caffeine/codeine]

acetaminophen/chlorpheniraminemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/chlorpheniramine/dextromethorphanmonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/chlorpheniramine/dextromethorphan/phenylephrinemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/chlorpheniramine/phenylephrinemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/codeinemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/dextromethorphanmonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/dextromethorphan/phenylephrinemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)[acetaminophen/dextromethorphan/phenylephrine: acetaminophen/dextromethorphan/phenylephrine, acetaminophen/dextromethorphan/phenylephrine/guaifenesin]

acetaminophen/dextromethorphan/pseudoephedrinemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)[acetaminophen/dextromethorphan/pseudoephedrine: acetaminophen/dextromethorphan/pseudoephedrine/guaifenesin]

acetaminophen/diphenhydraminemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/diphenhydramine/dextromethorphanmonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/diphenhydramine/phenylephrinemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/doxylamine/dextromethorphanmonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/doxylamine/dextromethorphan/phenylephrinemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/doxylamine/dextromethorphan/pseudoephedrinemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/doxylamine/phenylephrinemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/magnesium salicylate/pamabrommonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/pamabrommonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/pheniramine/phenylephrinemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/phenylephrinemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)[acetaminophen/phenylephrine: acetaminophen/phenylephrine, acetaminophen/phenylephrine/guaifenesin]

acetaminophen/pseudoephedrinemonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)[acetaminophen/pseudoephedrine: acetaminophen/pseudoephedrine/guaifenesin]

acetaminophensmonitor renal fxn: combo may incr. risk of nephrotoxicity (mechanism unknown)[acetaminophens: acetaminophen, acetaminophen rectal, acetaminophen/guaifenesin, isometheptene/dichloralphenazone/acetaminophen]

adefovir dipivoxilcaution advised, monitor renal fxn: combo may incr. adefovir levels, risk of nephrotoxicity (absorption increased)

aliskirenmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

aliskiren/amlodipinemonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

aliskiren/amlodipine/hydrochlorothiazidemonitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

aliskiren/hydrochlorothiazidemonitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

aliskiren/valsartanmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

amlodipine/ARB combosmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[amlodipine/ARB combos: amlodipine/olmesartan, amlodipine/valsartan, telmisartan/amlodipine]

amlodipine/ARB/thiazide combosmonitor BP, renal fxn: combo w/ NSAIDs may decr. diuretic, natriuretic, antihypertensive effects of thiazide diuretics; incr. risk of nephrotoxicity (antagonistic effects; additive effects)[amlodipine/ARB/thiazide combos: amlodipine/valsartan/hydrochlorothiazide, olmesartan/amlodipine/hydrochlorothiazide]

amlodipine/benazeprilmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

ARB/thiazide combosmonitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[ARB/thiazide combos: azilsartan/chlorthalidone, candesartan/hydrochlorothiazide, eprosartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, olmesartan/hydrochlorothiazide, telmisartan/hydrochlorothiazide, valsartan/hydrochlorothiazide]

ARBsmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[ARBs: azilsartan, candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan]

butalbital/acetaminophenmonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

carbamazepinemonitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects)

chamomile, Germancaution advised w/ large doses of German chamomile: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[chamomile, German: chamomile, German (Matricaria recutita), chamomile, Hungarian, chamomile, wild, Chamomilla recutita, Matricaria chamomilla, Matricaria recutita, pin heads]

cyclosporinemonitor renal fxn, BP, electrolytes: combo may incr. risk of nephrotoxicity, HTN, electrolyte abnormalities, edema, other adverse effects (additive toxicity)[cyclosporine: cyclosporine modified, cyclosporine non-modified]

desmopressinmonitor sodium: combo w/ NSAIDs may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects)[desmopressin: desmopressin, desmopressin nasal]

desvenlafaxinecaution advised, monitor sodium: combo may incr. risk of bleeding, SIADH, hyponatremia (NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake; additive effects)

diuretics, potassium-sparingcaution advised, monitor potassium: combo may decr. diuretic, natriuretic, antihypertensive effects of diuretics; some NSAIDs may incr. risk of hyperkalemia (antagonistic effects, additive effects)[diuretics, potassium-sparing: amiloride, spironolactone, triamterene]

drospirenonemonitor potassium: combo of NSAIDs and drospirenone may incr. risk of hyperkalemia (additive effects)[drospirenone: drospirenone/estradiol, drospirenone/ethinyl estradiol, drospirenone/ethinyl estradiol/levomefolate]

duloxetinecaution advised, monitor sodium: combo may incr. risk of bleeding, SIADH, hyponatremia (NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake; additive effects)

eplerenonemonitor BP, potassium: combo may decr. antihypertensive efficacy, incr. risk of severe hyperkalemia (antagonistic effects, additive effects)

exenatidecaution advised, monitor renal fxn: combo may incr. risk of nephrotoxicity (additive toxicity)

hydralazinemonitor BP: combo may decr. antihypertensive efficacy (antagonistic effects)

hydrocodone/acetaminophenmonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

isosorbide dinitrate/hydralazinemonitor BP: combo may decr. antihypertensive efficacy (antagonistic effects)

liraglutidecaution advised, monitor renal fxn: combo may incr. risk of nephrotoxicity (additive toxicity)

lithiummonitor levels: combo may incr. lithium levels, risk of toxicity (renal excretion decreased)

milnaciprancaution advised, monitor sodium: combo may incr. risk of bleeding, SIADH, hyponatremia (NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake; additive effects)

olanzapine/fluoxetinecaution advised, monitor sodium: combo w/ fluoxetine may incr. risk of bleeding, SIADH, hyponatremia (NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake; additive effects)

oxycodone/acetaminophenmonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

pamidronatemonitor renal fxn: combo may incr. risk of nephrotoxicity (additive effects)

pentazocine/acetaminophenmonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

polyethylene glycol/electrolytesmonitor sodium: combo may incr. risk of seizures (hyponatremia, other electrolyte abnormalities)[polyethylene glycol/electrolytes: polyethylene glycol/electrolytes, polyethylene glycol/electrolytes and bisacodyl, polyethylene glycol/electrolytes/sodium ascorbate/ascorbic acid]

propoxyphene/acetaminophenmonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)[propoxyphene/acetaminophen: propoxyphene hydrochloride/acetaminophen, propoxyphene napsylate/acetaminophen]

red clovercaution advised w/ large doses of red clover: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects, red clover has coumarin constituents)[red clover: beebread, cow clover, daidzein, genistein, meadow clover, purple clover, red clover (Trifolium pratense), trefle des pres, trefoil, Trifolium pratense, wild clover]

sodium phosphatesmonitor renal fxn, sodium: combo may incr. risk of nephrotoxicity, seizures (overlapping toxicity, hyponatremia, other electrolyte abnormalities)[sodium phosphates: sodium phosphate, sodium phosphate rectal]

sodium sulfate/potassium sulfate/magnesium sulfatecaution advised; consider monitoring renal fxn, electrolytes: combo may incr. risk of fluid and electrolyte abnormalities (altered renal excretion)

SSRIs, allcaution advised, monitor sodium: combo may incr. risk of bleeding, SIADH, hyponatremia (NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake; additive effects)[SSRIs, all: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, vilazodone]

telavancinmonitor renal fxn: combo may incr. risk of nephrotoxicity (additive effects)

tramadol/acetaminophenmonitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

trandolapril/verapamilmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

trazodonecaution advised, monitor sodium: combo may incr. risk of bleeding, SIADH, hyponatremia (NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake; additive effects)

venlafaxinecaution advised, monitor sodium: combo may incr. risk of bleeding, SIADH, hyponatremia (NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake; additive effects)

zoledronic acidmonitor renal fxn: combo may incr. risk of nephrotoxicity (additive effects)

Caution Advised

aldesleukincaution advised: combo may incr. risk of nephrotoxicity (additive toxicity)

antiplateletscaution advised: combo may incr. risk of bleeding (additive effects)[antiplatelets: anagrelide, cilostazol, clopidogrel, dipyridamole, prasugrel, ticagrelor, ticlopidine]

bisphosphonates, oralcaution advised: combo may incr. risk of upper GI adverse effects (additive effects)[bisphosphonates, oral: alendronate, alendronate/cholecalciferol, etidronate, ibandronate, risedronate, risedronate/calcium carbonate, tiludronate]

black cohoshcaution advised: combo may incr. risk of hepatotoxicity (additive toxicity)[black cohosh: Actaea racemosa, baneberry, black cohosh (Actaea racemosa), black

snakeroot, bugbane, bugwort, Cimicifuga racemosa, macrotys, rattle root, rattlesnake root, rattletop, rattleweed, squawroot]

budesonidecaution advised: combo may incr. risk of sodium and water retention, edema (additive effects)

capsicumcaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[capsicum: African chilies, capsaicin, capsicum (Capsicum annuum), Capsicum annuum, cayenne, chili pepper, green chili pepper, Louisiana long pepper, Mexican chilies, paprika, pimento, red pepper, tabasco pepper]

collagenase clostridium histolyticumcaution advised: combo may incr. risk of bleeding (additive effects)

corticosteroids, systemiccaution advised: combo may incr. risk of GI bleeding, sodium/water retention, edema (additive effects)[corticosteroids, systemic: betamethasone sodium phosphate/betamethasone acetate, cortisone, dexamethasone, dexamethasone sodium phosphate, hydrocortisone, hydrocortisone sodium succinate, methylprednisolone, methylprednisolone acetate, methylprednisolone sodium succinate, prednisolone, prednisone, triamcinolone acetonide]

darunavircaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)

dasatinibcaution advised: combo may incr. risk of bleeding (additive effects)

deferasiroxcaution advised: combo may incr. risk of GI bleeding, adverse effects (additive effects)

desirudincaution advised: combo may incr. risk of bleeding (additive effects)

diuretics, loopcaution advised: combo may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[diuretics, loop: bumetanide, ethacrynic acid, furosemide, torsemide]

diuretics, potassium-sparing/thiazide comboscaution advised: combo may decr. diuretic, natriuretic, antihypertensive effects of diuretics; some NSAIDs may incr. risk of hyperkalemia (antagonistic effects; additive effects)[diuretics, potassium-sparing/thiazide combos: amiloride/hydrochlorothiazide, spironolactone/hydrochlorothiazide, triamterene/hydrochlorothiazide]

diuretics, thiazidecaution advised: combo may decr. diuretic, natriuretic, antihypertensive effects of thiazides (antagonistic effects)[diuretics, thiazide: chlorothiazide, chlorthalidone, clonidine/chlorthalidone, hydralazine/hydrochlorothiazide, hydrochlorothiazide, indapamide, methyclothiazide, metolazone]

donepezilcaution advised: combo may incr. risk of GI bleeding (additive effects)

dong quaicaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[dong quai: Angelica atropurpurea, Angelica dahurica, Angelica sinensis, Chinese angelica, dang gui, dong quai (Angelica sinensis), ligustilides, Radix Angelicae Sinensis, tang-kuei]

erlotinibcaution advised: combo w/ NSAIDs may incr. risk of GI bleeding, perforation (mechanism unknown, erlotinib may incr. INR)

evening primrose oilcaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[evening primrose oil: evening primrose oil (Oenothera biennis), fever plant, king's cureall, night willow-herb, Oenothera biennis, scabish, stella di sera, sun drop]

fenugreekcaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[fenugreek: bird's foot, bockshornsamen, chilbe, fenugreek (Trigonella foenum-graecum), foenugraeci semen, Greek hay, griechische Heusamen, hu lu ba, methi, Trigonella foenum-graecum]

feverfewcaution advised: combo may incr. risk of bleeding; combo may decr. feverfew efficacy (additive antiplatelet effects; competitive prostaglandin inhibition)[feverfew: altamisa, bachelor's button, camomille grande, Chrysanthemum parthenium, featherfew, featherfoil, feverfew (Tanacetum parthenium), flirtwort midsummer daisy, midsummer daisy, Santa Maria, Tanacetum parthenium]

flaxseedcaution advised w/ flaxseed oil: combo may incr. risk of bleeding (additive antiplatelet effects)[flaxseed: flax, flaxseed (Linum usitatissimum), graine de lin, leinsamen, lini semen, linoleic acid, linseed, lint bells, Linum usitatissimum]

galantaminecaution advised: combo may incr. risk of GI bleeding (additive effects)

garliccaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[garlic: ail, ajo, Allium sativum, camphor of the poor, da-suan, garlic (Allium sativum), knoblauch, la-suan, nectar of the Gods, poor man's treacle, rust treacle, stinking rose]

gingercaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[ginger: African ginger, black ginger, cochin ginger, ginger (Zingiber officinale), Imber, Jamaica ginger, race ginger, rhizoma zingerberis, sheng jiang, Shokyo, Zingiber officinale, Zingiberis rhizoma]

ginkgo bilobacaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[ginkgo biloba: Eun-haeng, fossil tree, ginkgo (Ginkgo biloba), Ginkgo biloba, ginkyo, icho, ityo, Japanese silver apricot, kew tree, maidenhair tree, salisburia, silver apricot]

ginseng, Asiancaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[ginseng, Asian: ginseng radix, ginseng root, ginseng, Asian (Panax ginseng), ginseng, Chinese, ginseng, Japanese, ginseng, Korean, jintsam, ninjin, Panax ginseng, red ginseng, ren shen]

ginseng, Siberiancaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[ginseng, Siberian: Acanthopanax senticosus, devil's bush, eleuthero, eleutherococcus, Eleutherococcus senticosus, ginseng, Siberian (Eleutherococcus senticosus), shigoka, thorny pepperbush, Touch-Me-Not, untouchable, wild pepper]

green teacaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[green tea: Camellia sinensis, Camellia thea, Chinese tea, green tea (Camellia sinensis), green tea extract, GTE, Japanese tea, Matsu-cha tea, Theaceae, theifers]

horse chestnut seedcaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[horse chestnut seed: aescin, Aesculus hippocastanum, chestnut, de marronier d'Inde, escine, hippocastani semen, horse chestnut seed (Aesculus hippocastanum), marronier, venostasin, venostat]

ibuprofen/famotidinecaution advised: combo may incr. NSAID adverse effects (duplicate tx)

iloprost inhaledcaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)

kavacaution advised: combo may incr. risk of hepatotoxicity (additive toxicity)[kava: ava pepper, awa, intoxicating pepper, kao, kava (Piper methysticum), kawa, kew, Piper methysticum, sakau, tonga, yagona]

leflunomidecaution advised: combo may incr. NSAID adverse effects (hepatic metab. inhibited)

licoricecaution advised, may be used for therapeutic advantage: combo may incr. risk of fluid retention; combo may protect against NSAID-induced GI mucosal damage (additive toxicity; protective GI effect of licorice)[licorice: alcacuz, Chinese licorice, gan cao, gan zao, Glycyrrhiza glabra, Lakritzenwurzel, licorice (Glycyrrhiza glabra), orozuz, Russian licorice, Spanish licorice, sweet root]

neostigminecaution advised: combo may incr. risk of GI bleeding (additive effects)

NSAIDs, ophthalmiccaution advised: combo may incr. ocular bleeding risk postop (additive effects)[NSAIDs, ophthalmic: bromfenac ophthalmic, diclofenac ophthalmic, flurbiprofen ophthalmic, ketorolac ophthalmic, nepafenac ophthalmic]

omega-3-acidcaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[omega-3-acid: omega-3-acid ethyl esters]

platelet GP IIb/IIIa inhibitorscaution advised: combo may incr. risk of bleeding (additive effects)[platelet GP IIb/IIIa inhibitors: abciximab, eptifibatide, tirofiban]

porfimercaution advised: combo may decr. efficacy of photodynamic tx; antiplatelet agents may decr. thromboxane A2-mediated tumor necrosis (antagonistic effects)

pralatrexatecaution advised: combo may incr. pralatrexate levels, risk of toxicity (renal excretion decreased)

pyridostigminecaution advised: combo may incr. risk of GI bleeding (additive effects)

quinolones, allcaution advised: combo may incr. risk of CNS stimulation, seizures (mechanism unknown)[quinolones, all: ciprofloxacin, gemifloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin]

rivaroxabancaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)

rivastigminecaution advised: combo may incr. risk of GI bleeding (additive effects)[rivastigmine: rivastigmine, rivastigmine transdermal]

sibutraminecaution advised: combo may incr. risk of bleeding (synergistic effects, NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake)

tacrinecaution advised: combo may incr. risk of GI bleeding (additive effects)

thrombin inhibitorscaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[thrombin inhibitors: antithrombin (recombinant), antithrombin III, argatroban, dabigatran, lepirudin]

thrombolyticscaution advised: combo may incr. risk of bleeding (additive effects)[thrombolytics: alteplase, reteplase, tenecteplase]

tipranavircaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)

treprostinilcaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[treprostinil: treprostinil, treprostinil inhaled]

valproic acid derivativescaution advised: combo may incr. risk of bleeding, valproic acid exerts antiplatelet effects (additive effects)[valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid]

willow barkcaution advised: combo may incr. risk of bleeding, adverse effects (additive effects, willow bark may contain salicylates)[willow bark: basket willow, bay willow, brittle willow, osier rouge, purple osier, salicis cortex, Salix alba, Salix fragilis, Salix pentandra, Salix purpurea, violet willow, white willow, willow bark (Salix spp.)]

Adverse Reactions

Serious Reactions

Brand Discontinued in US

Common Reactions

Brand Discontinued in US

Safety/Monitoring

Pregnancy: --

Lactation: --

Look/Sound-Alike Drug Names [from www.usp.org]

Toradol confused with: Foradil; Inderal; Nizoral; Stadol; Tegretol; Tofranil; Torecan; tramadol; Tridil

ketorolac confused with: Kenalog; Kerlone

Pharmacology

Metabolism: --

Excretion: --

Subclass: NSAIDs

Mechanism of Action--

Manufacturer/Pricing

Manufacturer: Roche Laboratories

DEA/FDA: --

Approximate Retail Price

from  www.drugstore.com

This information is currently not available for this drug.

Patient Education

Nombre Genérico: ketorolac

Nombres de las Marcas: Toradol, Toradol IM, Toradol IV/IM

¿Cuál es la información más importante que debo saber sobre ketorolac?

Esta medicina puede aumentar su riesgo de problemas al corazón o de la circulación que pongan su vida en peligro, que incluyen ataques al corazón o accidentes cerebrovasculares. No use esta medicina justo antes o después de tener una cirugía de bypass arterial coronario con injerto (también conocida como CABG (por sus siglas en Inglés)).

Busque atención médica de emergencia si nota síntomas de problemas del corazón o de la circulación, como dolor de pecho, debilidad, falta de aire al respirar, o problemas de la visión o del balance.

Esta medicina también puede aumentar su riesgo a tener efectos secundarios graves del estómago o intestinos, que incluye sangrado o perforación (formación de hueco). Estas condiciones pueden causar la muerte y los efectos secundarios gastrointestinales pueden ocurrir en cualquier momento sin ninguna advertencia mientras esté tomando ketorolac. Los ancianos pueden estar a más riesgo de los efectos secundarios graves gastrointestinales.

Hable de inmediato con su médico si nota síntomas de sangrado del estómago o intestinos. Esto incluye heces fecales negras, con sangre, o color de arcilla, o sangre al toser, o vómito que tiene apariencia a café molido.

No consuma alcohol mientras esté tomando ketorolac. El alcohol puede aumentar el riesgo de sangrado del estómago que causa ketorolac.

¿Qué es ketorolac?

Ketorolac pertenece al grupo de drogas denominadas drogas antiinflamatorias no esteroides (AINES). Ketorolac funciona reduciendo las hormonas que causan inflamación y dolor en el cuerpo.

Ketorolac se usa por tiempo limitado (5 días o menos) para el tratamiento del dolor moderado a severo.

Ketorolac puede también usarse para propósitos diferentes a los que están incluidos en esta guía del medicamento.

¿Qué debería discutir con el profesional de la salud antes de tomar ketorolac?

No use esta medicina si tiene alergia a ketorolac, aspirin, u otro AINE (NSAIDs), o si usted tiene:

enfermedad aguda del riñón; problema de sangrado o coágulos de sangre;

una herida interna de la cabeza o sangrado cerebral;

historial de úlcera del estómago o sangrado intestinal; o

si le está dando de lactar al bebé.

No tome ketorolac si también está tomando pentoxifylline (Trental) o probenecid (Benemid). No tome ketorolac con aspirina u otros AINES/NSAIDs como ibuprofen (Motrin, Advil), naproxen (Aleve, Naprosyn), diclofenac (Voltaren), diflunisal (Dolobid), etodolac (Lodine), flurbiprofen (Ansaid), indomethacin (Indocin), ketoprofen (Orudis), ketorolac (Toradol), mefenamic acid (Ponstel), meloxicam (Mobic), nabumetone (Relafen), o piroxicam (Feldene).

Esta medicina puede aumentar su riesgo de problemas al corazón o de la circulación que pongan su vida en peligro, que puede incluir ataques del corazón o accidentes cerebrovasculares. Este riesgo aumentará con el uso prolongado de ketorolac. No use esta medicina inmediatamente antes o después de tener una cirugía de bypass arterial coronario con injerto (también conocida como CABG (por sus siglas en Inglés)).

Los AINES (NSAIDs, por sus siglas en Inglés) también pueden aumentar su riesgo de tener efectos secundarios de gravedad del estómago o intestinos, que incluyen sangrado o perforación (formación de hueco). Estas condiciones pueden causar la muerte y los efectos gastrointestinales pueden ocurrir sin ninguna advertencia en cualquier momento mientras esté tomando un AINE. Los adultos de edad avanzada pueden tener un riesgo mas alto de los efectos secundarios de gravedad gastrointestinales.

Antes de tomar ketorolac, dígale a su médico si usted tiene alergia a alguna droga, o si tiene:

historial de ataque al corazón, accidente cerebrovascular, o coágulos de sangre; enfermedad del corazón, falla cardíaca congestiva, presión arterial alta;

enfermedad del hígado o del riñón,

colitis ulcerosa o enfermedad de Crohn;

asma;

pólipos en su nariz;

si usted recientemente tuvo una cirugía; o

si fuma.

Si usted padece de alguna de estas condiciones, quizás necesite modificar su dosis o pruebas especiales para que pueda usar esta medicina con seguridad.

Clasificado por la FDA en la categoría C de riesgos a la gestación. Esta medicina le puede hacer daño al bebé nonato. El uso de ketorolac durante el trabajo de parto puede aumentar el riesgo de sangrar durante el nacimiento del bebé. No tome ketorolac durante el embarazo a menos que su médico se lo indique hacerlo.

Esta medicina puede afectar su fertilidad (la habilidad de poder tener bebés). No tome Ketorolac mientras esté tratando de concebir.

Ketorolac pasa a la leche materna y puede hacerle daño al bebé lactante. No use Ketorolac sin antes hablar con su médico si le está dando de lactar al bebé.

No le dé esta medicina a personas menores de 18 años.

¿Cómo debo tomar ketorolac?

Tome esta medicina exactamente como se lo hayan recetado. No tome la medicina en cantidades mayores o por más tiempo de lo recomendado por su médico. Siga las instrucciones que vienen con su receta. Ketorolac no se usa para el tratamiento de dolores menores.

Ketorolac es usualmente usado primero en inyección y después en tableta. Ketorolac inyección se aplica mediante una jeringa en el músculo o en la vena. Su médico, enfermera, u otro profesional de la salud le aplicará esta inyección.

La tableta de ketorolac debe tomarse con un vaso de agua lleno.

Ketorolac por lo general se administra por 5 días o menos, considerándose el total combinado de inyección o de forma oral. El uso prolongado de ketorolac puede hacerle daño a los riñones o causar sangrado.

Si necesita someterse a algún tipo de cirugía, dígale al cirujano por adelantado si usted ha usado ketorolac recientemente.

Mantenga ketorolac a temperatura ambiente lejos de la humedad y el calor.

¿Qué sucede si dejo de tomar una dosis?

Ya que ketorolac a veces se toma cuando se necesita para del dolor, tal vez no tenga un horario fijo. Si usted recibe la inyección de ketorolac en el hospital o lugar similar, no se considera probable que se salte una dosis.

Si está tomando la medicina con regularidad, tome la dosis pasada tan pronto se acuerde. Si ya es hora para su próxima dosis, espere y tome la medicina en su próximo horario regular. No tome más medicina para alcanzar la dosis pasada.

¿Qué sucede si tomo una sobredosis?

Busque atención medica de emergencia si sospecha que ha usado demasiado de esta medicina.

Los síntomas de una sobredosis puede incluir náusea, vómito, dolor de estómago, adormecimiento, heces fecales negras o con sangre, tos con sangre, respiración no profunda, y desmayo.

¿Qué debo evitar mientras tomo ketorolac?

No use ninguna otra medicina sin receta para el resfriado, alergias, or medicinas para el dolor sin antes hablar con su médico o farmacéutico. Muchas medicinas que se obtienen sin receta contienen aspirin u otras medicinas similares a ketorolac (como ibuprofen, ketoprofen, o naproxen). Si toma algunos productos juntos usted podría tomar, sin intención, demasiado de este tipo de medicinas. Examine la etiqueta de las otras medicinas que use para ver si contienen aspirin, ibuprofen, ketoprofen, o naproxen.

No consuma alcohol mientras esté tomando ketorolac. El alcohol puede aumentar el riesgo de sangrado del estómago que causa ketorolac.

¿Cuáles son los efectos secundarios posibles de ketorolac?

Busque atención medica de emergencia si usted nota alguna de estos síntomas de una reacción alérgica: ronchas; dificultad al respirar; hinchazón de la cara, labios, lengua, o garganta.

Deje de tomar ketorolac y busque atención medica o hable de inmediato con su médico si usted tiene alguno de estos efectos secundarios de gravedad:

dolor de pecho, debilidad, falta de aire al respirar, habla que se arrastra, problemas con la visión o el balance;

heces fecales negras, con sangre, o alquitranadas;

toser sangre o vómito que parece café molido;

hinchazón o ganancia rápida de peso;

orinar menos de lo normal o nada;

náusea, dolor de estómago, fiebre baja, perdida del apetito, orina oscura, heces fecales de color de arcilla, o ictericia;

fiebre, dolor de garganta, dolor de cabeza, sarpullido con piel roja, con llagas, y se pela;

la primera señal de alguna llaga en la boca o sarpullido, aunque sea muy leve;

piel blanca, moretones, hormigueo intenso, entumecimiento, dolor, debilidad muscular; o

fiebre, dolor de cabeza, rigidez de la nuca, escalofríos, aumento de sensibilidad a luz, puntos morados en la piel, o convulsiones.

Efectos secundarios de menor gravedad pueden incluir:

malestar estomacal, náusea o vómito leve, diarrea, estreñimiento; acidez leve, dolor del estómago, hinchazón, gas;

mareos, nerviosismo, dolor de cabeza;

sudoración; o

zumbido en los oídos.

Esta lista no menciona todos los efectos secundarios y puede ser que ocurran otros. Dígale a su médico acerca de cualquier efecto secundario fuera de lo normal que le cause molestia. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

¿Qué otras drogas afectarán a ketorolac?

Dígale a su médico si está tomando un antidepresivo como citalopram (Celexa), duloxetine (Cymbalta), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem, Symbyax), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft), or venlafaxine (Effexor). Tomar estas medicinas con ketorolac pueden causarle moretes o sangrado fácilmente.

Antes de tomar ketorolac, dígale a su médico si usted está tomando:

anticoagulante como warfarin (Coumadin); lithium (Eskalith, Lithobid);

methotrexate (Rheumatrex, Trexall);

thiothixene (Navane);

alprazolam (Xanax);

diuréticos (para eliminar el agua) como furosemide (Lasix).

relajantes musculares;

esteroides (prednisone y otras);

medicinas para las convulsiones como carbamazepine (Carbatrol, Tegretol) or phenytoin (Dilantin);

una medicina para el corazón como candesartan (Atacand), eprosartan (Teveten), irbesartan (Avapro, Avalide), losartan (Cozaar, Hyzaar), valsartan (Diovan), telmisartan (Micardis), or olmesartan (Benicar); o

inhibidor ECA como benazepril (Lotensin), captopril (Capoten), fosinopril (Monopril), enalapril (Vasotec), lisinopril (Prinivil, Zestril), ramipril (Altace), y otras.

Esta lista no incluye todas las drogas y pueden existir otras que tengan interacciones con ketorolac. Dígale a su médico acerca de todas las medicinas que está tomando, ya sean recetadas o no. Estas deben incluir vitaminas, minerales, productos herbarios, y las drogas recetadas por otros médicos. No empiece a usar una nueva medicina sin primero decirle a su médico.

¿Dónde puedo obtener más información?

Su farmacéutico tiene más información acerca de ketorolac.

Drug

Lasixfurosemide

Entire Monograph

Black Box Warnings

Fluid and Electrolyte Depletion

potent diuretic in excessive amts can cause profound diuresis w/ water/electrolyte depletion; individualize dose and schedule w/ medical supervision

Adult Dosing

Dosage forms:  20,40,80

Dosage Forms Discontinued in US

[oral sol, IM, IV not avail. as brand; see generic]

edema

[PO route]Dose: 40-120 mg/day PO div qd-bid; Start: 20-80 mg PO x1, incr. 20-40 mg q6-8h; Max: 600 mg/day; Info: for pts w/ CHF, hepatic dz or renal dz; maint. dose may be given intermittently

[IM/IV route]Start: 20-40 mg IM/IV x1, incr. 20 mg q2h; Alt: 0.1 mg/kg IV x1, then 0.1 mg/kg/h, then double dose q2h up to 0.4 mg/kg/h; Info: for pts w/ CHF, hepatic dz or renal dz

pulmonary edema, acute

[80 mg IV q1h]Start: 40 mg IV x1

HTN

[10-40 mg PO bid]Start: 40 mg PO bid; Alt: start 10-20 mg PO bid; Max: 600 mg/day; Info: refer to JNC 7 guidelines

*hypercalcemia

[120 mg/day PO div qd-tid]Alt: 80-100 mg IM/IV q1-2h; Info: give w/ saline

renal dosing

[no adjustment]anuria: contraindicated; HD/PD: no supplement

hepatic dosing

[not defined]cirrhosis/ascites: caution advised

Peds Dosing

Dosage forms:  20,40,80

Dosage Forms Discontinued in US

[oral sol, IM, IV not avail. as brand; see generic]

edema

[PO route, neonates]Dose: 1-4 mg/kg PO qd-bid; Start: 2 mg/kg PO x1, incr. 1-2 mg/kg q6-8h; Max: 6 mg/kg/dose; Info: for pts w/ CHF, hepatic dz or renal dz; poor bioavailability when given PO

[PO route, infants/children]Dose: 1-6 mg/kg PO q12-24h; Start: 2 mg/kg PO x1, incr. 1-2 mg/kg q6-8h; Max: 6 mg/kg/dose; Info: for pts w/ CHF, hepatic dz or renal dz

[IM/IV route, neonates]Dose: 0.5-1 mg/kg IM/IV q8-24h; Start: 1 mg/kg IM/IV x1, incr. 1 mg/kg q2h; Max: 2 mg/kg/dose; Info: for pts w/ CHF, hepatic dz or renal dz

[IM/IV route, infants/children]Dose: 0.5-2 mg/kg IM/IV q6-12h; Start: 1 mg/kg IM/IV x1, incr. 1 mg/kg q2h; Max: 6 mg/kg/dose; Alt: 0.5 mg/kg/h, titrate to desired effect; Info: for pts w/ CHF, hepatic dz or renal dz

*hypercalcemia

[25-50 mg IM/IV q4h]Info: give w/ saline

renal dosing

[no adjustment]anuria: contraindicated; HD/PD: no supplement

hepatic dosing

[not defined]cirrhosis/ascites: caution advised

Contraindications/Cautions

hypersens. to drug/class/compon. anuria

hepatic coma

electrolyte imbalances

caution if hypersens. to sulfonamides

caution if diabetes mellitus

caution if acute MI

caution if arrhythmias

caution if hearing impairment

caution if concurrent ototoxic agents

caution if SLE

caution if hepatic impairment

caution if renal dz, severe

caution if urinary retention

caution if gout hx

caution if pancreatitis hx

caution in gestational HTN

caution in premature neonates

caution in elderly pts

caution if iodinated contrast

Drug Interactions

Avoid/Use Alternative

aminoglycosides, oralavoid combo or monitor closely: combo may incr. risk of nephrotoxicity, ototoxicity (additive toxicity)[aminoglycosides, oral: neomycin sulfate, paromomycin]

aminoglycosides, parenteralavoid combo or monitor closely: combo may incr. risk of ototoxicity, nephrotoxicity (additive toxicity)[aminoglycosides, parenteral: amikacin, gentamicin, kanamycin, streptomycin, tobramycin]

lithiumavoid combo or monitor levels closely: combo may incr. lithium levels, risk of toxicity (renal excretion decreased)

Monitor/Modify Tx

ACE inhibitor/thiazide combosmonitor BP, electrolytes; use for therapeutic advantage: combo may incr. risk of hypotension, dehydration, electrolyte abnormalities (synergistic effects)[ACE inhibitor/thiazide combos: benazepril/hydrochlorothiazide, captopril/hydrochlorothiazide, enalapril/hydrochlorothiazide, fosinopril/hydrochlorothiazide, lisinopril/hydrochlorothiazide, moexipril/hydrochlorothiazide, quinapril/hydrochlorothiazide]

ACE inhibitorsmonitor BP, use for therapeutic advantage: combo may incr. risk of hypotension (synergistic effects)[ACE inhibitors: benazepril, captopril, enalapril, enalaprilat, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, trandolapril]

acetaminophen/aspirincaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo w/ aspirin may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of ototoxicity, renal impairment (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)

acetaminophen/aspirin/caffeinecaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo w/ aspirin may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of

ototoxicity, renal impairment (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)

acetaminophen/magnesium salicylate/pamabromcaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of ototoxicity, renal impairment (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)

aliskiren/amlodipine/hydrochlorothiazidemonitor BP, electrolytes; use for therapeutic advantage: combo may decr. furosemide levels, efficacy; combo may incr. risk of hypotension, dehydration, electrolyte abnormalities (mechanism unknown; synergistic effects)

aliskiren/hydrochlorothiazidemonitor BP, electrolytes; use for therapeutic advantage: combo may decr. furosemide levels, efficacy; combo may incr. risk of hypotension, dehydration, electrolyte abnormalities (mechanism unknown; synergistic effects)

amifostinecaution advised, monitor BP: combo may incr. risk of hypotension (additive effects)

amlodipine/ARB combosmonitor BP, use for therapeutic advantage: combo may incr. risk of hypotension (synergistic effects)[amlodipine/ARB combos: amlodipine/olmesartan, amlodipine/valsartan, telmisartan/amlodipine]

amlodipine/ARB/thiazide combosmonitor BP, electrolytes; use for therapeutic advantage: combo may incr. risk of hypotension, dehydration, electrolyte abnormalities (synergistic effects)[amlodipine/ARB/thiazide combos: amlodipine/valsartan/hydrochlorothiazide, olmesartan/amlodipine/hydrochlorothiazide]

amlodipine/benazeprilmonitor BP, use for therapeutic advantage: combo may incr. risk of hypotension (synergistic effects)

amphotericinsmonitor electrolytes: combo may incr. risk of hypokalemia, other electrolyte abnormalities (additive effects)[amphotericins: amphotericin B cholesteryl sulfate, amphotericin B deoxycholate, amphotericin B lipid complex, amphotericin B liposomal]

antiarrhythmics, class IIImonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)[antiarrhythmics, class III: amiodarone, dofetilide, ibutilide, sotalol, sotalol AF]

ARB/thiazide combosmonitor BP, potassium, use for therapeutic advantage: combo may incr. risk of hypotension, hypokalemia (additive/synergistic effects)[ARB/thiazide combos: azilsartan/chlorthalidone, candesartan/hydrochlorothiazide, eprosartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, olmesartan/hydrochlorothiazide, telmisartan/hydrochlorothiazide, valsartan/hydrochlorothiazide]

ARBsmonitor BP, use for therapeutic advantage: combo may incr. risk of hypotension (synergistic effects)[ARBs: azilsartan, candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan]

arsenic trioxidemonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

artemether/lumefantrinemonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

asenapinemonitor potassium, BP: combo may incr. risk of QT prolongation, cardiac arrhythmias, hypotension (hypokalemia, other electrolyte abnormalities, additive effects)

aspirin/caffeinecaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo w/ aspirin may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of ototoxicity, renal impairment (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)

aspirin/calcium carbonatecaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of ototoxicity, renal impairment (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)

aspirin/chlorpheniramine/dextromethorphancaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of ototoxicity, renal insufficiency (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)

aspirin/chlorpheniramine/dextromethorphan/phenylephrinecaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of ototoxicity, renal insufficiency (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)

aspirin/chlorpheniramine/phenylephrinecaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of ototoxicity, renal insufficiency (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)

aspirin/diphenhydraminecaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of ototoxicity, renal insufficiency (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)

aspirin/doxylamine/dextromethorphan/phenylephrinecaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of ototoxicity, renal insufficiency (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)

aspirin/phenylephrinecaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of ototoxicity, renal insufficiency (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)

beta 2 agonists, allmonitor potassium: combo may incr. risk of hypokalemia (additive effects)[beta 2 agonists, all: albuterol, albuterol inhaled, arformoterol inhaled, budesonide/formoterol inhaled, fluticasone/salmeterol inhaled, formoterol inhaled, indacaterol inhaled, ipratropium bromide/albuterol inhaled, levalbuterol inhaled, metaproterenol, mometasone/formoterol inhaled, pirbuterol inhaled, salmeterol inhaled, terbutaline]

beta blocker/thiazide combosmonitor BP, electrolytes; use for therapeutic advantage: combo may incr. risk of hypotension, dehydration, electrolyte abnormalities (synergistic effects)[beta blocker/thiazide combos: atenolol/chlorthalidone, bisoprolol/hydrochlorothiazide, metoprolol succinate/hydrochlorothiazide, metoprolol tartrate/hydrochlorothiazide, nadolol/bendroflumethiazide, propranolol/hydrochlorothiazide]

bismuth subsalicylatecaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of ototoxicity, renal impairment (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)

bismuth subsalicylate/metronidazole/tetracyclinecaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy; may incr. risk of ototoxicity,

renal impairment (antagonistic effects; salicylate-induced inhibition of renal prostaglandins, sodium and fluid retention; additive effects)

bisphosphonates, injectablecaution advised, monitor calcium: loop diuretics may cause incr. urinary excretion of calcium, incr. risk of hypocalcemia (additive hypocalcemic effects)[bisphosphonates, injectable: pamidronate, zoledronic acid]

budesonidemonitor potassium: combo may incr. risk of hypokalemia (additive effects)

calcium channel blockers, othersmonitor BP, use for therapeutic advantage: combo may incr. risk of hypotension (synergistic effects)[calcium channel blockers, others: diltiazem, trandolapril/verapamil, verapamil]

carbonic anhydrase inhibitors, systemicmonitor potassium, electrolytes: combo may incr. risk of hypokalemia, other electrolyte abnormalities (additive effects)[carbonic anhydrase inhibitors, systemic: acetazolamide, methazolamide]

carboplatinmonitor renal fxn, electrolytes: combo may incr. risk of ototoxicity, electrolyte abnormalities (overlapping toxicity, additive effects)

cisapridemonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

cisplatinmonitor renal fxn, electrolytes: combo may incr. risk of ototoxicity, electrolyte abnormalities (overlapping toxicity, synergistic effects)

clarithromycinmonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

CNS depressant/aspirin/caffeine comboscaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of ototoxicity, renal impairment (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)[CNS depressant/aspirin/caffeine combos: butalbital/aspirin/caffeine, butalbital/aspirin/caffeine/codeine, dihydrocodeine/aspirin/caffeine]

corticosteroids, systemicmonitor potassium: combo may decr. diuretic efficacy, incr. risk of hypokalemia (antagonistic effects, additive effects)[corticosteroids, systemic: betamethasone sodium phosphate/betamethasone acetate,

cortisone, dexamethasone, dexamethasone sodium phosphate, hydrocortisone, hydrocortisone sodium succinate, methylprednisolone, methylprednisolone acetate, methylprednisolone sodium succinate, prednisolone, prednisone, triamcinolone acetonide]

crizotinibmonitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

dasatinibmonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

deferipronemonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

degarelixmonitor potassium w/ long-term degarelix tx: combo may incr. risk of QT prolongation, cardiac arrhythmias (additive QT prolongation risk w/ long-term androgen deprivation, hypokalemia, electrolyte abnormalities)

desvenlafaxinemonitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects)

dexlansoprazolemonitor magnesium: combo may incr. risk of hypomagnesemia (additive effects)

dextromethorphan/quinidinemonitor potassium: combo w/ quinidine may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

diazoxidemonitor BP, glucose, uric acid levels: combo may incr. diazoxide hyperglycemic, hyperuricemic, antihypertensive effects (synergistic effects)

digoxinmonitor potassium: loop diuretics may cause hypokalemia, incr. risk of digoxin toxicity (hypokalemia, other electrolyte abnormalities)

diuretics, potassium-sparing/thiazide combosmonitor BP, electrolytes; use for therapeutic advantage: combo may incr. risk of hypotension, dehydration, electrolyte abnormalities (synergistic effects)[diuretics, potassium-sparing/thiazide combos: amiloride/hydrochlorothiazide, spironolactone/hydrochlorothiazide, triamterene/hydrochlorothiazide]

diuretics, thiazidemonitor BP, electrolytes; use for therapeutic advantage: combo may incr. risk of

hypotension, dehydration, electrolyte abnormalities (synergistic effects)[diuretics, thiazide: chlorothiazide, chlorthalidone, clonidine/chlorthalidone, hydralazine/hydrochlorothiazide, hydrochlorothiazide, indapamide, methyclothiazide, metolazone]

dolasetronmonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

dronedaronemonitor potassium, electrolytes: combo may incr. risk of hypokalemia, QT prolongation, cardiac arrhythmias (additive effects, hypokalemia, other electrolyte abnormalities)

droperidolcaution advised, monitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

duloxetinemonitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects)

ephedramonitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)[ephedra: Chinese ephedra, desert herb, ephedra (Ephedra sinica), Ephedra sinica, herbal ecstasy, Indian joint fir, ma huang, popotillo, sea grape, yellow astringent, yellow horse]

ephedrinemonitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)[ephedrine: ephedrine, ephedrine/guaifenesin]

erythromycinsmonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)[erythromycins: erythromycin base, erythromycin ethylsuccinate, erythromycin lactobionate, erythromycin stearate, erythromycin/sulfisoxazole]

esomeprazolemonitor magnesium: combo may incr. risk of hypomagnesemia (additive effects)

exenatidemonitor renal fxn, glucose: combo may incr. risk of nephrotoxicity; may decr. hypoglycemic agent efficacy (additive toxicity; antagonistic effects, loop diuretics may cause hyperglycemia)

ezogabinemonitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia)

fingolimodmonitor ECG overnight and monitor potassium when starting or restarting fingolimod tx: combo may incr. risk of QT prolongation, cardiac arrhythmias (additive effects, hypokalemia)

GnRH agonistsmonitor potassium w/ long-term GnRH agonist tx: combo may incr. risk of QT prolongation, cardiac arrhythmias (additive QT prolongation risk w/ long-term androgen deprivation, hypokalemia, electrolyte abnormalities)[GnRH agonists: goserelin, histrelin subcutaneous implant, leuprolide, triptorelin]

haloperidolmonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)[haloperidol: haloperidol, haloperidol decanoate, haloperidol lactate]

hypoglycemics, othermonitor glucose: combo may decr. hypoglycemic agent efficacy; loop diuretics may cause hyperglycemia (antagonistic effects)[hypoglycemics, other: acarbose, metformin, miglitol, nateglinide, repaglinide, repaglinide/metformin, sitagliptin/metformin]

iloperidonemonitor potassium, BP: combo may incr. risk of QT prolongation, cardiac arrhythmias, hypotension (hypokalemia, other electrolyte abnormalities, additive effects)

insulinsmonitor glucose: combo may incr. insulin requirement, loop diuretics may cause hyperglycemia (antagonistic effects)[insulins: insulin aspart, insulin aspart protamine/insulin aspart, insulin detemir, insulin glargine, insulin glulisine, insulin lispro, insulin lispro protamine/insulin lispro, insulin NPH, insulin NPH/regular, insulin regular]

isoproterenolmonitor potassium: combo may incr. risk of hypokalemia (additive effects)

lansoprazolemonitor magnesium: combo may incr. risk of hypomagnesemia (additive effects)

lansoprazole/amoxicillin/clarithromycinmonitor magnesium, potassium, other electrolytes: combo w/ clarithromycin may incr. risk of QT prolongation, cardiac arrhythmias; combo w/ lansoprazole may incr. risk of hypomagnesemia (hypokalemia, other electrolyte abnormalities; additive effects)

lapatinibmonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

linagliptinmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects)

linagliptin/metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, loop diuretics may cause hyperglycemia)

liraglutidemonitor renal fxn, glucose: combo may incr. risk of nephrotoxicity; may decr. hypoglycemic agent efficacy (additive toxicity; antagonistic effects, loop diuretics may cause hyperglycemia)

lopinavir/ritonavirmonitor potassium, electrolytes: combo may incr. risk of QT interval prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

lurasidonemonitor BP: combo may incr. risk of hypotension (additive effects)

metformin/sulfonylurea combosmonitor glucose: combo may decr. hypoglycemic agent efficacy; loop diuretics may cause hyperglycemia (antagonistic effects)[metformin/sulfonylurea combos: glipizide/metformin, glyburide/metformin]

methadonemonitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

mifepristonemonitor potassium if daily mifepristone use: combo may incr. risk of hypokalemia, QT prolongation, cardiac arrhythmias (additive effects)

milnacipranmonitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects)

naproxen/esomeprazolecaution advised; monitor magnesium: combo w/ NSAIDs may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity; combo w/ PPI may incr. risk of hypomagnesemia (antagonistic effects, additive effects; additive effects)

nesiritidemonitor BP: combo may incr. risk of hypotension (additive/synergistic effects)

nilotinibmonitor potassium, electrolytes: combo may incr. risk of hypokalemia, QT prolongation, cardiac arrhythmias (additive effects, hypokalemia, other electrolyte abnormalities)

NSAID/chlorpheniramine/pseudoephedrine combosmonitor renal fxn: combo w/ NSAIDs may decr. diuretic, natriuretic, antihypertensive

effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[NSAID/chlorpheniramine/pseudoephedrine combos: ibuprofen/chlorpheniramine/pseudoephedrine]

NSAID/diphenhydramine combosmonitor renal fxn: combo w/ NSAIDs may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[NSAID/diphenhydramine combos: ibuprofen/diphenhydramine]

NSAID/phenylephrine combosmonitor renal fxn: combo w/ NSAIDs may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[NSAID/phenylephrine combos: ibuprofen/phenylephrine]

NSAID/pseudoephedrine combosmonitor renal fxn: combo w/ NSAIDs may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[NSAID/pseudoephedrine combos: ibuprofen/pseudoephedrine, naproxen sodium/pseudoephedrine]

octreotidemonitor fluid and electrolytes; consider lower diuretic dose: combo may alter diuretic requirements, incr. risk of electrolyte abnormalities (additive effects, antagonistic effects)

omeprazolemonitor magnesium: combo may incr. risk of hypomagnesemia (additive effects)[omeprazole: omeprazole, omeprazole/sodium bicarbonate]

omeprazole/clarithromycin/amoxicillinmonitor magnesium, potassium, other electrolytes: combo w/ clarithromycin may incr. risk of QT prolongation, cardiac arrhythmias; combo w/ omeprazole may incr. risk of hypomagnesemia (hypokalemia, other electrolyte abnormalities; additive effects)

ondansetronmonitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

oprelvekinmonitor fluid and electrolytes w/ chronic diuretic tx: combo may incr. risk of severe hypokalemia (mechanism unknown)

paliperidonemonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)[paliperidone: paliperidone, paliperidone palmitate]

pantoprazolemonitor magnesium: combo may incr. risk of hypomagnesemia (additive effects)

pentamidinemonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

phenothiazinesmonitor potassium, electrolytes: combo w/ loop diuretics may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)[phenothiazines: chlorpromazine, fluphenazine, fluphenazine decanoate, perphenazine, prochlorperazine edisylate, prochlorperazine maleate, prochlorperazine rectal, promethazine, promethazine rectal, thioridazine, trifluoperazine]

pimozidemonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

polyethylene glycol/electrolytesmonitor electrolytes: combo may incr. risk of seizures (electrolyte abnormalities)[polyethylene glycol/electrolytes: polyethylene glycol/electrolytes, polyethylene glycol/electrolytes and bisacodyl, polyethylene glycol/electrolytes/sodium ascorbate/ascorbic acid]

promethazine/codeinemonitor potassium, electrolytes: combo of loop diuretics w/ phenothiazines may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

propafenonemonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

quetiapinemonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

quinine sulfatemonitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

quinolones, QT prolongersmonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)[quinolones, QT prolongers: gemifloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin]

rabeprazolemonitor magnesium: combo may incr. risk of hypomagnesemia (additive effects)

ranolazinemonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

salicylatescaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of ototoxicity, renal impairment (inhibition of renal prostaglandins, sodium and fluid retention, additive effects)[salicylates: aspirin, aspirin/dipyridamole, carisoprodol/aspirin, choline magnesium trisalicylate, magnesium salicylate, oxycodone/aspirin, salsalate]

saquinavirmonitor potassium, electrolytes: combo may incr. risk of hypokalemia, QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

saxagliptinmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, loop diuretics may cause hyperglycemia)

saxagliptin/metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, loop diuretics may cause hyperglycemia)

sitagliptinmonitor glucose: combo may decr. hypoglycemic agent efficacy; loop diuretics may cause hyperglycemia (antagonistic effects)

sitagliptin/simvastatinmonitor glucose: combo may decr. hypoglycemic agent efficacy; loop diuretics may cause hyperglycemia (antagonistic effects)

sodium phosphatesmonitor renal fxn, electrolytes: combo may incr. risk of nephrotoxicity, electrolyte abnormalities, QT prolongation, cardiac arrhythmias (overlapping toxicity, additive effects, electrolyte abnormalities)[sodium phosphates: sodium phosphate, sodium phosphate rectal]

sodium sulfate/potassium sulfate/magnesium sulfatemonitor renal fxn, electrolytes: combo may incr. risk of nephrotoxicity, seizures, QT prolongation, cardiac arrhythmias (additive effects, electrolyte abnormalities)

SSRIs, allmonitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects)[SSRIs, all: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, vilazodone]

sulfonylureasmonitor glucose: combo may decr. sulfonylurea efficacy, loop diuretics may cause hyperglycemia (antagonistic effects)[sulfonylureas: chlorpropamide, glimepiride, glipizide, glyburide, glyburide micronized, tolazamide, tolbutamide]

sunitinibmonitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

telavancinmonitor potassium, electrolytes, renal fxn: combo may incr. risk of QT prolongation, cardiac arrhythmias, nephrotoxicity (hypokalemia, other electrolyte abnormalities, additive effects)

telithromycinmonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

tetrabenazinemonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

thiazolidinedionesmonitor glucose: combo may decr. hypoglycemic agent efficacy; loop diuretics may cause hyperglycemia (antagonistic effects)[thiazolidinediones: pioglitazone, pioglitazone/glimepiride, pioglitazone/metformin, rosiglitazone, rosiglitazone/glimepiride, rosiglitazone/metformin]

tizanidinecaution advised, monitor BP: combo may incr. risk of hypotension (additive effects)

toremifenemonitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

trazodonemonitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects)

venlafaxinemonitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects)

ziprasidonecaution advised, monitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

Caution Advised

aldesleukincaution advised: combo may incr. risk of hypotension (additive effects)

aliskirencaution advised: combo may decr. furosemide levels, efficacy (mechanism unknown)

aliskiren/amlodipinecaution advised: combo may decr. furosemide levels, efficacy (mechanism unknown)

aliskiren/valsartanconsider alternatives; monitor BP, use for therapeutic advantage: combo may decr. furosemide levels, efficacy; may incr. risk of hypotension (mechanism unknown; synergistic effects)

allopurinolcaution advised: combo may decr. hypouricemic efficacy (antagonistic effects)

apomorphinecaution advised: combo may incr. risk of orthostatic hypotension, MI, pneumonia, falls, other apomorphine adverse effects (additive effects)

celecoxibcaution advised: combo may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

diclofenac topicalcaution advised: combo may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects; up to 10% systemic absorption of diclofenac topical; minimal absorption w/ patch)[diclofenac topical: diclofenac epolamine topical, diclofenac topical]

febuxostatcaution advised: combo may decr. hypouricemic efficacy (antagonistic effects)

ginseng, Asiancaution advised: combo may result in diuretic resistance (mechanism unknown)[ginseng, Asian: ginseng radix, ginseng root, ginseng, Asian (Panax ginseng), ginseng, Chinese, ginseng, Japanese, ginseng, Korean, jintsam, ninjin, Panax ginseng, red ginseng, ren shen]

hydrocodone/ibuprofencaution advised: combo may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

ibuprofen/famotidinecaution advised: combo w/ ibuprofen may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects; additive effects)

iloprost inhaledcaution advised: combo may incr. risk of hypotension (additive/synergistic effects)

licoricecaution advised: combo may incr. risk of hypokalemia, adverse effects (additive effects)[licorice: alcacuz, Chinese licorice, gan cao, gan zao, Glycyrrhiza glabra,

Lakritzenwurzel, licorice (Glycyrrhiza glabra), orozuz, Russian licorice, Spanish licorice, sweet root]

MAOIs, non-selectivecaution advised: combo may incr. risk of hypotension (additive effects)[MAOIs, non-selective: isocarboxazid, phenelzine, procarbazine, selegiline transdermal, tranylcypromine]

maraviroccaution advised: combo may incr. risk of orthostatic hypotension (additive effects)

neuromuscular blockers, non-depol.caution advised: combo may potentiate, prolong neuromuscular blockade (mechanism unknown, electrolyte imbalances may contribute)[neuromuscular blockers, non-depol.: atracurium, cisatracurium, pancuronium, rocuronium, vecuronium]

nitrites/sodium thiosulfatecaution advised: combo w/ nitrites may incr. risk of hypotension (additive effects)[nitrites/sodium thiosulfate: amyl nitrite/sodium nitrite/sodium thiosulfate, sodium nitrite/sodium thiosulfate]

NSAIDscaution advised: combo may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[NSAIDs: diclofenac potassium, diclofenac sodium, diclofenac/misoprostol, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, ibuprofen lysine, indomethacin, ketoprofen, ketorolac, ketorolac nasal, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, naproxen sodium, oxaprozin, piroxicam, sulindac, tolmetin]

oxycodone/ibuprofencaution advised: combo may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

pegloticasecaution advised: combo may decr. hypouricemic efficacy (antagonistic effects)

probenecidcaution advised: combo may decr. hypouricemic efficacy (antagonistic effects)

sildenafilcaution advised: combo may incr. risk of symptomatic hypotension (additive effects)

sumatriptan/naproxen sodiumcaution advised: combo w/ NSAIDs may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

tadalafilcaution advised: combo may incr. risk of hypotension (additive effects)

treprostinilcaution advised: combo may incr. risk of symptomatic hypotension (additive effects)[treprostinil: treprostinil, treprostinil inhaled]

Adverse Reactions

Serious Reactions

hypokalemia, severe electrolyte imbalance, severe

metabolic alkalosis

hypovolemia/dehydration

ototoxicity

thrombocytopenia

anemia, hemolytic

aplastic anemia

leukopenia

agranulocytosis

anaphylaxis

vasculitis

interstitial nephritis

necrotizing angiitis

erythema multiforme

exfoliative dermatitis

Stevens-Johnson syndrome

toxic epidermal necrolysis

pancreatitis

cholestatic jaundice

SLE exacerbation

thrombosis

eosinophilia

rash w/ eosinophilia and systemic sx

exanthematous pustulosis, acute generalized

Common Reactions

urinary frequency dizziness

nausea/vomiting

weakness

muscle cramps

hypokalemia

hypomagnesemia

hypotension, orthostatic

ALT, AST elevated

blurred vision

anorexia

abdominal cramps

diarrhea

pruritus

rash

hyperuricemia

hyperglycemia

hypocalcemia

tinnitus

paresthesia

photosensitivity

cholesterol incr.

triglycerides incr.

Safety/Monitoring

Pregnancy: C, see Contraind/Caut. (FDA category C but trimester-specific or population-specific risks exist; see Contraind/Caut. and pkg insert for more info)

Lactation: Safety Unknown (Inadequate literature available to assess risk; caution advised)

Monitoring Parameters BUN/Cr, serum CO2, electrolytes frequently early in tx, then periodically; CBC; Plt; LFTs; urine/blood glucose especially if diabetes or suspected latent diabetes; consider renal ultrasound (peds pts)

Look/Sound-Alike Drug Names [from www.usp.org]

Lasix confused with: Lanoxin; Lomotil; Lovenox; Luvox

furosemide confused with: famotidine; finasteride; fluconazole; fluoxetine; fosinopril; loperamide; torsemide

Pharmacology

Metabolism: liver minimally; CYP450: unknown

Excretion: urine 88%, bile/feces 12%; Half-life: 30-60min

Subclass: Diuretics 1: Loop

Mechanism of Actioninhibits loop of Henle and proximal and distal convoluted tubule sodium and chloride resorption

Manufacturer/Pricing

Manufacturer: sanofi-aventis U.S. LLC

DEA/FDA: Rx: (Requires prescription; not a controlled substance)

Approximate Retail Price

from  www.drugstore.com

tablet:

20 mg (30 ea): $26.99 40 mg (30 ea): $26.99

80 mg (30 ea): $32.99

Patient Education

Nombre Genérico: furosemide

Nombre de la Marca: Lasix

¿Cuál es la información más importante que debo saber sobre furosemide?

No use esta medicina si usted no puede orinar.

Antes de usar esta medicamento, dígale a su médico si usted tiene enfermedad del riñón, próstata agrandada, problemas urinarios, cirrosis u otra enfermedad del hígado, un desequilibrio de electrólitos, colesterol elevado, la gota, lupus, diabetes, o una alergia a las drogas sulfa.

Dígale a su médico si usted recientemente ha tenido resonancia magnética (MRI por sus siglas en Ingles) o cualquier tipo de rastreo donde le inyectan una prueba de colorante en sus venas.

No tome más medicamento de lo recetado. Dosis altas de furosemide pueden causar una perdida de audición irreversible.

Furosemide hará que usted orine con más frecuencia y puede hacer que se deshidrate muy fácilmente. Siga las instrucciones de su médico acerca del uso de suplementos de potasio o de tener suficiente sal y potasio en su dieta.

Evite deshidratarse. Evite la exposición a la luz solar o camas para broncearse. Sigas las instrucciones de su médico acerca del tipo y la cantidad de líquidos que usted debe tomar mientras esté tomando furosemide.

Para estar seguro de que este medicamento no le está haciendo daño, habrá que examinar su sangre con frecuencia. Su función de su riñón puede también necesitar ser examinado. Visite a su médico con regularidad.

Si usted está recibiendo tratamiento para la presión arterial alta, siga usando esta medicina aunque se sienta bien. La presión arterial alta frecuentemente no tiene síntomas.

¿Qué es furosemide?

Furosemide es un diurético del asa (pastilla para excreción de orina) que impide que su cuerpo absorba demasiada sal, dejando mas bien que la sal pase con la orina..

Furosemide se usa en el tratamiento de la retención de líquidos acuoso (edema) en las personas con fallo cardíaco congestivo, enfermedad del hígado, o problemas del riñón como el síndrome nefrótico. Esta medicina también se usa para el tratamiento de la presión arterial elevada (hipertensión).

Furosemide puede también usarse para fines no mencionados en esta guía del medicamento.

¿Qué debería discutir con el profesional de la salud antes de tomar furosemide?

No use esta medicina si usted no puede orinar.

Para asegurarse que usted puede tomar furosemide de forma segura, dígale a su médico si usted tiene cualquiera de estas otras condiciones:

enfermedad del riñón; próstata agrandada, obstrucción de la vejiga u otros problemas urinarios;

cirrosis u otra enfermedad del hígado;

desequilibrio de electrólitos (como niveles bajos de potasio o magnesio en su sangre);

colesterol o triglicéridos elevados (un tipo de grasa en la sangre);

gota;

lupus;

diabetes; o

una alergia a sulfa drogas.

Dígale a su médico si usted recientemente ha tenido resonancia magnética (MRI por sus siglas en Ingles) o cualquier tipo de rastreo donde le inyectan una prueba de colorante en sus venas.

Categoría C del embarazo por la FDA. No se conoce si furosemide causará daño al bebé nonato. Dígale a su médico si usted está embarazada o planea quedar embarazada mientras está usando este medicamento.

Furosemide puede pasar a la leche materna y le puede hacer daño al bebé nonato. Este medicamento puede también retrasar la producción de leche materna. No use esta medicina sin primero hablar con su médico si usted le está dando de lactar al bebé.

¿Cómo debo tomar furosemide?

Tómelo exactamente como lo haya recetado su médico. No lo tome en cantidades mayores o menores, o por más tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripción.

No tome más medicamento de lo recetado. Dosis altas de furosemide pueden causar una perdida de audición irreversible.

Tal vez su médico en ocasiones cambie su dosis para asegurarse de que está obteniendo los mejores resultados.

Mida la medicina líquida con una cucharita o taza de medición, no lo haga con una cuchara normal. Si no tiene con qué medir su medicina, pídale una a su farmacéutico.

Furosemide hará que usted orine con más frecuencia y puede hacer que se deshidrate muy fácilmente. Siga las instrucciones de su médico acerca del uso de suplementos de potasio o de tener suficiente sal y potasio en su dieta.

Para estar seguro de que este medicamento no le está haciendo daño, habrá que examinar su sangre con frecuencia. Su función de su riñón puede también necesitar ser examinado. Visite a su médico con regularidad.

Si usted está recibiendo tratamiento para la presión arterial alta, siga usando esta medicina aunque se sienta bien. La presión arterial alta frecuentemente no tiene síntomas.

Guarde a temperatura ambiente fuera de la humedad, el calor, y la luz.

La medicina líquida de furosemide debe ser usada dentro de 60 a 90 días después de abrir la botella. Pregúntele a su farmacéutico por cuántos días su medicina está en buen estado. Bote cualquier líquido que no haya usado después de que ese tiempo haya pasado.

¿Qué sucede si me salto una dosis?

Furosemide a veces se usa solamente una vez, y tal vez no necesite mantener un horario regular. Si está usando esta medicina en un horario regular, tome la dosis pasada tan pronto se acuerde.

Sáltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome más medicina para alcanzar la dosis pasada.

¿Qué sucede si tomo una sobredosis?

Busque atención médica de emergencia o llame a la línea de Poison Help al 1-800-222-1222.

Los síntomas de una sobredosis pueden incluir zumbido en los oídos, perdida del apetito, debilidad, mareo, confusión, sensación de mareado, o desmayo.

¿Qué debo evitar mientras tomo furosemide?

Evite levantarse muy rápido de la posición de sentado o acostado, ya que puede sentirse mareado. Levántese despacio y estabilícese para evitar que se caiga.

Evite deshidratarse. Sigas las instrucciones de su médico acerca del tipo y la cantidad de líquidos que usted debe tomar mientras esté tomando furosemide.

Evite la exposición a la luz solar o camas para broncearse. Furosemide puede hacer que se queme más fácilmente. Póngase ropa que lo proteja y use un bloqueador con filtro solar (de SPF 30 o mayor) si usted está afuera.

¿Cuáles son los posibles efectos secundarios de furosemide?

Busque atención medica de emergencia si usted tiene alguno de estos síntomas de una reacción alérgica: ronchas, dificultad para respirar, hinchazón de la cara, labios, lengua, o garganta.

Deje de usar furosemide y llame a su médico de inmediato si usted tiene un efecto secundario grave como:

zumbido en sus oídos, perdida de la audición; sentirse muy sediento o caliente, sudar fuertemente, o piel caliente y seca;

orinar con dolor o dificultad;

fiebre, glándulas hinchadas, dolor de cuerpo, síntomas de la gripe;

sarpullido, moretones o sangrado fácil, hormigueo severo, dolor, entumecimiento o debilidad repentina;

dolor de pecho, ritmo cardíaco irregular, tos nueva o que empeora con fiebre, dificultad para respirar;

confusión, vómito, hinchazón, ganancia de peso rápida, orinar menos de lo usual o nada en absoluto;

piel pálida, sangrado inusual (nariz, boca, vagina, o recto), manchas debajo de la piel en forma de puntos morados o rojos;

sentir que se va a desmayar o le falta aire al respirar, paso cardíaco rápido, dificultad para concentrarse;

náusea, dolor en la parte superior del estómago, picazón, pérdida del apetito, orina oscura, heces fecales de color arcilla, ictericia (color amarillo de la piel u ojos);

boca seca, aumento de sed, somnolencia, sentirse inquieto, confusión, aumento de querer orinar, dolor o debilidad musculares, desmayo, o convulsiones;

entumecimiento o sensación de hormigueo alrededor su boca, opresión o contracción del músculo, reflejos hiperactivos;

dolor de cabeza, pérdida del apetito, sensación de inestabilidad, respiración superficial o respiración que se detiene; o

reacción severa de la piel -- fiebre, dolor de garganta, hinchazón en su cara o lengua, quemazón en sus ojos, dolor de la piel, seguido por un sarpullido rojo o púrpura que se extiende (especialmente en la cara o la parte superior del cuerpo) y causa ampollas y descamación.

Efectos secundarios de menor gravedad pueden incluir:

diarrea, estreñimiento, dolor de estómago; mareo, sensación de girar;

visión borrosa; o

picazón o sarpullido leves.

Esta lista no menciona todos los efectos secundarios y puede ser que ocurran otros. Llame a su médico para consejos médicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

Qué otras drogas afectarán a furosemide?

Si usted toma sucralfate (Carafate), tómelo por lo menos 2 horas antes o después de tomar furosemide.

Dígale a su médico acerca de todas las medicinas que usted use, especialmente:

cyclosporine (Neoral, Gengraf, Sandimmune); digoxin (Lanoxin);

ethacrynic acid (Edecrin);

indomethacin (Indocin);

lithium (Eskalith, Lithobid);

methotrexate (Rheumatrex, Trexall);

phenytoin (Dilantin);

medicinas para el cáncer (quimioterapia);

pastillas para dieta o el resfriado;

esteroides (prednisone y otros);

un laxante (Metamucil, Milk of Magnesia, Colace, Dulcolax, epsom salts, senna, y otras);

un antibiótico como cefdinir (Omnicef), cefprozil (Cefzil), cefuroxime (Ceftin), cephalexin (Keflex), y otras;

un antibiótico como amikacin (Amikin), gentamicin (Garamycin), kanamycin (Kantrex), neomycin (Mycifradin, Neo Fradin, Neo Tab), paromycin (Humatin, Paromycin), streptomycin, tobramycin (Nebcin, Tobi);

medicamento para el corazón o la presión arterial como benazepril (Lotensin), candesartan (Atacand), eprosartan (Teveten), enalapril (Vasotec), irbesartan (Avapro, Avalide), lisinopril (Prinivil, Zestril), losartan (Cozaar, Hyzaar), olmesartan (Benicar), quinapril (Accupril), ramipril (Altace), telmisartan (Micardis), valsartan (Diovan), y otras; o

salicilatos como aspirin, Disalcid, Doan's Pills, Dolobid, Salflex, Tricosal, y otros.

Esta lista no incluye todas las drogas y pueden existir otras que tengan interacciones con furosemide. Dígale a su médico acerca de todos los medicamentos que usted use. Incluya los productos que se obtienen con o sin receta, vitaminas, y productos herbarios. No empiece a usar un medicamento nuevo sin primero decirle a su médico.

¿Dónde puedo obtener más información?

Su farmacéutico le puede dar más información acerca de furosemide.

Drug

Dilantinphenytoin

Entire Monograph

Black Box Warnings

Cardiovascular Risk with Rapid Infusion

IV infusion should not exceed 50 mg/min in adults or 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in peds pts; incr. risk severe hypotension and cardiac arrhythmias above recommended infusion rate, but events also reported at or below recommended rate; monitor cardiac adverse events during and after IV infusion; IV infusion rate reduction or D/C may be necessary; EDITORIAL NOTE: expert guidelines suggest slower rates of 25-50 mg/min (healthy adults), 10-20 mg/min (elderly or cardiac dz), <1 mg/kg/min (peds pts), and 0.5 mg/kg/min (neonates) may decr. risk of tissue or vascular injury, hypotension, or other adverse events

Adult Dosing

Dosage forms:  50 CH; 30,100 ER; 125/5 mL

Dosage Forms Discontinued in US

[IM, IV not avail. as brand; see generic]

Special Note

[formulation clarification]Info: phenytoin ER caps contain 8% less drug than chewable tabs and susp; monitor closely and consider dose adjustment if switching between products

status epilepticus

[initial tx]Dose: 15-20 mg/kg IV x1; Info: may give additional 10 mg/kg IV x1 after 20min if no response to initial dose; begin maint. dose 12h after loading dose

[maintenance tx]

Dose: 100 mg PO/IV q6-8h; Info: adjust dose based on tx response and serum levels

seizure disorder

[extended-release form]Dose: 300-400 mg/day ER PO div bid-tid; Max: 400 mg/dose ER; Alt: 4-7 mg/kg/day ER PO div bid-tid; Info: may consider load of 15-20 mg/kg ER PO div in 3 doses 2-4h apart; adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs; if stable on bid-tid ER dosing, then may switch to qd ER dosing; do not open/crush/chew

[immediate-release form]Dose: 300-400 mg/day PO/IV div bid-tid; Max: 400 mg/dose; Alt: 4-7 mg/kg/day PO/IV div bid-tid; Info: may consider load of 15-20 mg/kg PO/IV div in 3 doses 2-4h apart; adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs

seizure prophylaxis, neurosurgery-assoc.

[IV route]Dose: 4-6 mg/kg/day IV div bid-tid; Start: load 10-20 mg/kg IV div in 3 doses 2-4h apart; Max: 400 mg/dose; Info: IV route preferred to IM route

[IM route]Dose: 100-200 mg IM q4h; Max: x1wk; Alt: give 150% of usual daily PO dose by IM route div q4h; Info: decr. usual PO dose by 50% for same duration as IM was used when converting back from IM to PO

renal dosing

[no adjustment]renal impairment: do not give oral loading regimen; HD/PD: no supplement

hepatic dosing

[adjust dose amount]hepatic impairment: do not give oral loading regimen

Peds Dosing

Dosage forms:  50 CH; 30,100 ER; 125/5 mL

Dosage Forms Discontinued in US

[IV not avail. as brand; see generic]

Special Note

[formulation clarification]Info: phenytoin ER caps contain 8% less drug than chewable tabs and susp; monitor closely and consider dose adjustment if switching between products

status epilepticus

[15-20 mg/kg IV x1]Max: 1500 mg/day; Info: may give additional 10 mg/kg IV x1 after 20min if no response to initial dose; begin maint. dose 12h after loading dose

seizure disorder

[immediate-release form, <6 mo]Dose: 5-8 mg/kg/day PO/IV div bid-tid; Start: 5 mg/kg/day PO/IV div bid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs

[immediate-release form, 6 mo-4 yo]Dose: 8-10 mg/kg/day PO/IV div bid-tid; Start: 5 mg/kg/day PO/IV div bid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs

[immediate-release form, 4-7 yo]Dose: 7.5-9 mg/kg/day PO/IV div bid-tid; Start: 5 mg/kg/day PO/IV div bid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs

[immediate-release form, 7-10 yo]Dose: 7-8 mg/kg/day PO/IV div bid-tid; Start: 5 mg/kg/day PO/IV div bid-tid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs

[immediate-release form, 10-16 yo]Dose: 6-7 mg/kg/day PO/IV div bid-tid; Start: 5 mg/kg/day PO/IV div bid-tid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs

[immediate-release form, >16 yo]see Adult Dosing

[extended-release form, 7-10 yo]Dose: 7-8 mg/kg/day ER PO div bid-tid; Start: 5 mg/kg/day ER PO div bid-tid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs; if stable on bid-tid ER dosing, then may switch to qd ER dosing; do not open/crush/chew

[extended-release form, 10-16 yo]Dose: 6-7 mg/kg/day ER PO div bid-tid; Start: 5 mg/kg/day ER PO div bid-tid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs; if stable on bid-tid ER dosing, then may switch to qd ER dosing; do not open/crush/chew

[extended-release form, >16 yo]see Adult Dosing

renal dosing

[no adjustment]

hepatic dosing

[adjust dose amount]hepatic impairment: decr. dose, amount not defined

Contraindications/Cautions

hypersens. to drug/class/compon. SA block (IM or IV use)

2nd or 3rd degree AV block (IM or IV use)

sinus bradycardia (IM or IV use)

Adams-Stokes syndrome (IM or IV use)

caution if hypotension (IM or IV use)

caution if cardiovascular dz (IM or IV use)

caution if renal impairment

caution if hepatic impairment

caution if diabetes mellitus

caution if pregnancy

caution in elderly pts

caution if porphyria

caution if alcohol use

caution if thyroid dz

avoid abrupt withdrawal

caution if HLA-B*1502-positive

caution if depression or hx

Drug Interactions

Contraindicated

boceprevircontraindicated: combo may decr. boceprevir levels, efficacy (hepatic metab. induced)

delavirdinecontraindicated: combo may decr. delavirdine levels, efficacy (hepatic metab. induced)

emtricitabine/rilpivirine/tenofovir disoproxilcontraindicated: combo may decr. rilpivirine levels, efficacy (hepatic metab. induced)

etravirinecontraindicated: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

lopinavir/ritonavircontraindicated w/ once daily lopinavir/ritonavir; use alternative or weigh risk/benefit w/ other regimens; monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

lurasidonecontraindicated: combo may decr. lurasidone levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

praziquantelcontraindicated; D/C phenytoin 4wk prior to praziquantel course, may restart phenytoin 1 day after last dose praziquantel: combo may decr. praziquantel levels, efficacy (hepatic metab. induced)

ranolazinecontraindicated: combo may decr. ranolazine levels, efficacy (hepatic metab. induced)

rilpivirinecontraindicated: combo may decr. rilpivirine levels, efficacy (hepatic metab. induced)

Avoid/Use Alternative

acetaminophen/codeineuse alternative or limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy; incr. risk of CNS and respiratory depression, psychomotor impairment (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

axitinibavoid combo: combo may decr. axitinib levels, efficacy (hepatic metab. induced)

bortezomibavoid combo: combo may decr. bortezomib levels, efficacy (hepatic metab. induced)

bosutinibavoid combo: combo may decr. bosutinib levels, efficacy (hepatic metab. induced)

cabazitaxelavoid combo: combo may decr. cabazitaxel levels, efficacy (hepatic metab. induced)

calcium channel blockers, dihydropyridinesuse alternative or monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)[calcium channel blockers, dihydropyridines: amlodipine, amlodipine/benazepril, felodipine, isradipine, nicardipine, nifedipine, nimodipine, nisoldipine]

calcium channel blockers, othersuse alternative or monitor for efficacy: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)[calcium channel blockers, others: diltiazem, trandolapril/verapamil, verapamil]

cobicistatavoid combo: combo may decr. cobicistat levels, efficacy (hepatic metab. induced)[cobicistat: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil]

contraceptives, oral combocaution advised; use additional non-hormonal or alternative contraception: combo may result in loss of seizure control; combo may decr. hormonal contraceptive levels, efficacy (estrogen-induced fluid retention; hepatic metab. induced)[contraceptives, oral combo: desogestrel/ethinyl estradiol, drospirenone/ethinyl estradiol, drospirenone/ethinyl estradiol/levomefolate, estradiol valerate/dienogest, ethynodiol/ethinyl estradiol, levonorgestrel/ethinyl estradiol, norethindrone/ethinyl estradiol, norethindrone/mestranol, norgestimate/ethinyl estradiol, norgestrel/ethinyl estradiol]

contraceptives, oral progestinuse additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)[contraceptives, oral progestin: norethindrone]

contraceptives, other combocaution advised; use additional non-hormonal or alternative contraception: combo may result in loss of seizure control; combo may decr. hormonal contraceptive levels, efficacy (estrogen-induced fluid retention; hepatic metab. induced)[contraceptives, other combo: etonogestrel/ethinyl estradiol vaginal, norelgestromin/ethinyl estradiol transdermal]

crizotinibavoid combo or use alternative: combo may decr. crizotinib levels, efficacy (hepatic metab. induced)

deferasiroxavoid combo or consider incr. initial deferasirox dose to 30 mg/kg/day, monitor ferritin and phenytoin levels: combo may decr. deferasirox efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; hepatic metab. inhibited)

dopamineuse alternative or monitor BP: combo w/ IV phenytoins may incr. risk of severe hypotension (mechanism unknown, possible additive effects)

dronedaroneavoid combo: combo may decr. dronedarone levels, efficacy (hepatic metab. induced)

elvitegraviravoid combo or use alternative: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)[elvitegravir: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil]

enzalutamideavoid combo: combo may decr. levels of both drugs, efficacy (hepatic metab. induced)

erlotinibuse alternative or consider incr. erlotinib dose >150 mg/day: combo may decr. erlotinib levels (hepatic metab. induced)

etonogestrel subdermal implantuse additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)

everolimusavoid combo or adjust dose based on indication; incr. everolimus dose up to 20 mg/day in breast CA, PNET, renal cell CA, or renal angiomyolipoma w/ TSC pts; double everolimus dose and monitor levels in SEGA pts; monitor levels in transplant pts: combo may decr. everolimus levels, efficacy (hepatic metab. induced)

ginkgo bilobaavoid consumption of raw ginkgo seeds: combo may decr. anticonvulsant efficacy (antagonistic effects, high dose ginkgotoxin may cause seizures)[ginkgo biloba: Eun-haeng, fossil tree, ginkgo (Ginkgo biloba), Ginkgo biloba, ginkyo, icho, ityo, Japanese silver apricot, kew tree, maidenhair tree, salisburia, silver apricot]

hydrocodone/acetaminophenuse alternative or limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy; incr. risk of CNS and respiratory depression, psychomotor impairment (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

irinotecanavoid combo or use alternative; consider switch to non-enzyme inducing anticonvulsant >2wk prior to irinotecan start: combo may decr. irinotecan and active metabolite levels, efficacy (hepatic metab. induced)

ivacaftoravoid combo: combo may decr. ivacaftor levels, efficacy (hepatic metab. induced)

ixabepiloneuse alternative: combo may decr. ixabepilone levels, efficacy (hepatic metab. induced)

lapatinibavoid combo or consider incr. lapatinib dose gradually up to 4500 mg/day; monitor phenytoin levels: combo may decr. lapatinib levels, efficacy; may incr. phenytoin levels, risk of adverse effects, toxicity (hepatic metab. induced; hepatic metab. inhibited)

levonorgestreluse alternative non-hormonal contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)

linagliptinuse alternative: combo may decr. linagliptin levels, efficacy (hepatic metab. induced, p-glycoprotein induced, antagonistic effects)

linagliptin/metforminuse alternative: combo may decr. linagliptin levels, efficacy (hepatic metab. induced, P-glycoprotein induced)

local anestheticsavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)[local anesthetics: bupivacaine, bupivacaine liposomal, chloroprocaine, lidocaine, mepivacaine, procaine, ropivacaine]

local anesthetics/epinephrineavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)[local anesthetics/epinephrine: articaine/epinephrine]

medroxyprogesterone acetateuse additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)

methotrexateuse alternative or monitor efficacy, toxicity, levels: combo may incr. methotrexate toxicity and decr. efficacy; may decr. phenytoin levels, efficacy (mechanism unknown; absorption decreased)

mifepristoneavoid combo if daily mifepristone use; caution advised if pregnancy termination use: combo may decr. mifepristone levels, efficacy (hepatic metab. induced)

milk thistleavoid combo or monitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects (hepatic metab. inhibited)[milk thistle: Carduus marianum, holy thistle, Lady's thistle, legalon, Marian thistle, Mary thistle, milk thistle (Silybum marianum), silibinin, silybin, Silybum marianum, silymarin, St. Mary thistle]

nilotinibavoid combo or consider incr. nilotinib dose and monitor ECG, phenytoin levels: combo may incr. phenytoin levels, risk of toxicity; may decr. phenytoin or nilotinib levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

oxycodone/acetaminophenuse alternative or limit acetaminophen <2 g/day: combo may decr. oxycodone levels, efficacy; incr. risk of acetaminophen toxicity, decr. efficacy; incr. risk of CNS and respiratory depression, psychomotor impairment (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

pazopanibcontraindicated if chronic use of strong CYP3A4 inducer, otherwise avoid combo or use alternative: combo may decr. pazopanib levels, efficacy (hepatic metab. induced)

pentazocine/acetaminophenuse alternative or limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy; incr. risk of CNS and respiratory depression, psychomotor impairment (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

posaconazoleweigh risk/benefit, monitor phenytoin levels: combo may decr. posaconazole levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. altered)

rivaroxabanavoid combo: combo may decr. rivaroxaban levels, efficacy (hepatic metab. induced, P-glycoprotein induced)

roflumilastavoid combo: combo may decr. roflumilast levels, efficacy (hepatic metab. induced)

sunitinibuse alternative or consider incr. sunitinib dose to max 87.5 mg/day in GIST or RCC pts and max 62.5 mg/day in PNET pts: combo may decr. sunitinib levels, efficacy (hepatic metab. induced)

tadalafilavoid combo in pulmonary HTN pts; caution advised for ED pts: combo may decr. tadalafil levels, efficacy (hepatic metab. induced)

telapreviravoid combo or monitor phenytoin levels and titrate dose: combo may alter phenytoin levels, decr. efficacy or incr. toxicity; may decr. telaprevir levels, efficacy (hepatic metab. altered; hepatic metab. induced, p-glycoprotein induced)

temsirolimusavoid combo or consider incr. temsirolimus dose to 50 mg/wk: combo may decr. temsirolimus and sirolimus levels, efficacy (hepatic metab. induced)

ticagreloravoid combo: combo may decr. ticagrelor levels, efficacy (hepatic metab. induced)

tolvaptanavoid combo or consider incr. tolvaptan dose: combo may decr. tolvaptan levels, efficacy (hepatic metab. induced)

tramadolavoid combo: combo may decr. tramadol levels, efficacy; may incr. risk of CNS depression, psychomotor impairment, alter seizure control (hepatic metab. induced; additive effects, decr. seizure threshold)

tramadol/acetaminophenuse alternative: combo may incr. risk of acetaminophen toxicity, decr. tramadol levels and efficacy; incr. risk of CNS depression, psychomotor impairment; tramadol may decr. seizure threshold (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

ulipristaluse alternative non-hormonal contraception: combo may decr. ulipristal levels, contraceptive efficacy (hepatic metab. induced)

vandetanibavoid combo: combo may decr. vandetanib levels, efficacy (hepatic metab. induced)

Monitor/Modify Tx

acarbosemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

acetaminophen/aspirincaution advised, especially w/ high dose aspirin or salicylates, monitor phenytoin levels; limit acetaminophen <2 g/day: combo w/ aspirin may incr. phenytoin levels, risk of toxicity; combo may incr. risk of acetaminophen toxicity, decr. efficacy (protein binding displacement; hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/aspirin/caffeinecaution advised, especially w/ high dose aspirin or salicylates, monitor phenytoin levels; limit acetaminophen <2 g/day: combo w/ aspirin may incr. phenytoin levels, risk of toxicity; combo may decr. caffeine levels, efficacy; combo may incr. risk of acetaminophen toxicity, decr. efficacy (protein binding displacement; hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/caffeinecaution advised; limit acetaminophen <2 g/day: combo may decr. caffeine levels, efficacy; combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/caffeine/CNS depressant comboscaution advised, limit acetaminophen <2 g/day: combo may decr. caffeine levels, efficacy; may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic acetaminophen metabolite formation)[acetaminophen/caffeine/CNS depressant combos: acetaminophen/caffeine/dihydrocodeine, butalbital/acetaminophen/caffeine, butalbital/acetaminophen/caffeine/codeine]

acetaminophen/chlorpheniraminecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/chlorpheniramine/dextromethorphancaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/chlorpheniramine/dextromethorphan/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/chlorpheniramine/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/dextromethorphancaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/dextromethorphan/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophen/dextromethorphan/phenylephrine: acetaminophen/dextromethorphan/phenylephrine, acetaminophen/dextromethorphan/phenylephrine/guaifenesin]

acetaminophen/dextromethorphan/pseudoephedrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophen/dextromethorphan/pseudoephedrine: acetaminophen/dextromethorphan/pseudoephedrine/guaifenesin]

acetaminophen/diphenhydraminecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/diphenhydramine/dextromethorphancaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/diphenhydramine/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/doxylamine/dextromethorphancaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/doxylamine/dextromethorphan/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/doxylamine/dextromethorphan/pseudoephedrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/doxylamine/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/magnesium salicylate/pamabromcaution advised, especially w/ high dose aspirin or salicylates, monitor phenytoin levels; limit acetaminophen <2 g/day: combo w/ salicylates may incr. phenytoin levels, risk of toxicity; combo may incr. risk of acetaminophen toxicity, decr. efficacy (protein binding displacement; hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/pamabromcaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced, incr. toxic metabolite formation)

acetaminophen/pheniramine/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophen/phenylephrine: acetaminophen/phenylephrine, acetaminophen/phenylephrine/guaifenesin]

acetaminophen/pseudoephedrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophen/pseudoephedrine: acetaminophen/pseudoephedrine/guaifenesin]

acetaminophenscaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

[acetaminophens: acetaminophen, acetaminophen rectal, acetaminophen/guaifenesin, isometheptene/dichloralphenazone/acetaminophen]

acyclovirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown)

aliskiren/amlodipinemonitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)

aliskiren/amlodipine/hydrochlorothiazidemonitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)

amiodaronemonitor levels, efficacy: combo may incr. phenytoin levels, risk of toxicity; decr. amiodarone levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

amlodipine/ARB combosmonitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)[amlodipine/ARB combos: amlodipine/olmesartan, amlodipine/valsartan, telmisartan/amlodipine]

amlodipine/ARB/thiazide combosmonitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)[amlodipine/ARB/thiazide combos: amlodipine/valsartan/hydrochlorothiazide, olmesartan/amlodipine/hydrochlorothiazide]

amlodipine/atorvastatinmonitor BP, cholesterol levels: combo may decr. both statin and calcium channel blocker levels, efficacy (hepatic metab. induced)

antacidsgive oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)[antacids: aluminum hydroxide, aluminum hydroxide/magnesium carbonate, aluminum hydroxide/magnesium hydroxide, aluminum hydroxide/magnesium hydroxide/simethicone, aluminum hydroxide/magnesium trisilicate, magnesium hydroxide]

aprepitantcaution advised, monitor efficacy: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)[aprepitant: aprepitant, fosaprepitant]

aripiprazoleadjust aripiprazole dose, may be doubled up to max 30 mg/day: combo may decr. aripiprazole levels, efficacy (hepatic metab. induced)

aspirincaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/caffeinecaution advised, especially w/ high dose aspirin or salicylates, monitor phenytoin levels: combo w/ aspirin may incr. phenytoin levels, risk of toxicity; combo may decr. caffeine levels, efficacy (protein binding displacement; hepatic metab. induced)

aspirin/calcium carbonategive oral phenytoin 2h before or 4h after oral calcium salts; caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo w/ calcium may decr. phenytoin levels, efficacy; combo w/ aspirin may incr. phenytoin levels, risk of toxicity (absorption decreased; protein binding displacement)

aspirin/chlorpheniramine/dextromethorphancaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/chlorpheniramine/dextromethorphan/phenylephrinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/chlorpheniramine/phenylephrinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/diphenhydraminecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/dipyridamolecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/doxylamine/dextromethorphan/phenylephrinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/phenylephrinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

atazanavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

bexarotenecaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

bismuth subcitrate potassium/metronidazole/tetracyclinemonitor levels: combo w/ metronidazole may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

bismuth subsalicylate/metronidazole/tetracyclinemonitor levels: combo w/ metronidazole, salicylates may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited, protein binding displacement)

bosentancaution advised, monitor phenytoin levels: combo may decr. bosentan levels, decr. phenytoin levels (hepatic metab. induced)

butalbital/acetaminophencaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced, incr. toxic acetaminophen metabolite formation)

calcitriolmonitor efficacy; consider calcitriol dose adjustment: enzyme induction may decr. endogenous calcitriol levels, resulting in incr. supplemental calcitriol requirements (hepatic metab. induced)

calcium carbonate/magnesium hydroxidegive oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)[calcium carbonate/magnesium hydroxide: calcium carbonate/magnesium hydroxide, calcium carbonate/magnesium hydroxide/simethicone]

calcium saltsgive phenytoin 2h before or 4h after oral calcium salts: combo may decr. phenytoin levels, efficacy (absorption decreased)[calcium salts: calcium acetate, calcium carbonate, calcium carbonate/simethicone, calcium chloride, calcium citrate, calcium gluconate, risedronate/calcium carbonate]

capecitabinemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown)

carbamazepinemonitor levels: combo may alter levels of both drugs; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

carisoprodol/aspirincaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

carisoprodol/aspirin/codeinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. risk of CNS depression, psychomotor impairment; combo may incr. phenytoin levels, risk of toxicity (additive effects; protein binding displacement)

carvedilolmonitor efficacy: combo may decr. carvedilol levels, efficacy (hepatic metab. induced)

caspofunginconsider incr. caspofungin dose to 70 mg/day in adults, 70 mg/m^2 in peds: combo may decr. caspofungin levels, efficacy (hepatic metab. induced)

chloramphenicolmonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

cimetidinemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

cinacalcetmonitor iPTH, serum calcium: combo may decr. cinacalcet levels, efficacy (hepatic metab. induced)

ciprofloxacinmonitor levels: combo may incr. or decr. phenytoin levels (hepatic metab. altered)

clarithromycinmonitor phenytoin levels: combo may decr. clarithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown)

clopidogrelcaution advised, monitor phenytoin levels: may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

clozapinecaution advised, monitor for altered response to clozapine: combo may decr. clozapine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

CNS depressant/aspirin/caffeine comboscaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may decr. caffeine levels, efficacy; combo may incr. phenytoin levels, risk of toxicity (hepatic metab. induced; phenytoin protein binding displacement)

[CNS depressant/aspirin/caffeine combos: butalbital/aspirin/caffeine, butalbital/aspirin/caffeine/codeine, dihydrocodeine/aspirin/caffeine]

colesevelamgive phenytoin >4h before; monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (absorption decreased)

cyclosporinemonitor levels: combo may decr. cyclosporine levels, efficacy (hepatic metab. induced)[cyclosporine: cyclosporine modified, cyclosporine non-modified]

darunavirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

diazepamcaution advised, monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity; may incr. risk of CNS depression, psychomotor impairment (mechanism unknown; additive effects)[diazepam: diazepam, diazepam rectal]

digoxinmonitor digoxin levels: combo may decr. digoxin levels, efficacy (P-glycoprotein induced)

disopyramidemonitor levels: combo may decr. disopyramide levels, efficacy (hepatic metab. induced)

disulfirammonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

doxorubicinsmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown)[doxorubicins: doxorubicin, doxorubicin liposomal]

efavirenzcaution advised, monitor phenytoin levels: combo may decr. efavirenz levels, efficacy; alter phenytoin levels (hepatic metab. altered)

efavirenz/emtricitabine/tenofovir disoproxilcaution advised, monitor phenytoin levels: combo w/ efavirenz may alter phenytoin levels; decr. efavirenz levels, efficacy (hepatic metab. altered)

erythromycinsmonitor phenytoin levels: combo may decr. erythromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown)

[erythromycins: erythromycin base, erythromycin ethylsuccinate, erythromycin lactobionate, erythromycin stearate, erythromycin/sulfisoxazole]

ethosuximidemonitor ethosuximide levels: combo may decr. ethosuximide levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; mechanism unknown)

exemestaneadjust exemestane dose to 50 mg/day: combo may decr. exemestane levels, efficacy (hepatic metab. induced)

exenatidemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

ezogabineconsider incr. ezogabine dose; caution advised: combo may decr. ezogabine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

famotidine/calcium carbonate/magnesium hydroxidegive phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)

felbamatemonitor phenytoin levels, consider phenytoin dose reduction: combo may incr. phenytoin levels, risk of toxicity; decr. felbamate levels, efficacy (hepatic metab. altered)

fenofibratemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)[fenofibrate: fenofibrate, fenofibrate micronized, fenofibric acid]

fluconazolemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fluorouracilmonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fluoxetinemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fluvastatinmonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fluvoxaminemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fosamprenavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

gefitinibconsider incr. gefitinib dose to 500 mg/day: combo may decr. gefitinib levels, efficacy (hepatic metab. induced)

gemfibrozilmonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

growth hormonemonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)[growth hormone: somatropin (recombinant)]

guanfacineconsider incr. guanfacine dose: combo may decr. guanfacine levels, efficacy (hepatic metab. induced)

imatinibincr. imatinib dose 50%, monitor response: combo may decr. imatinib levels, efficacy (hepatic metab. induced)

indinavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

influenza vaccinecaution advised, monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown, hepatic metab. possibly inhibited)[influenza vaccine: influenza intradermal vaccine, influenza vaccine]

insulinsmonitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects)[insulins: insulin aspart, insulin aspart protamine/insulin aspart, insulin detemir, insulin glargine, insulin glulisine, insulin lispro, insulin lispro protamine/insulin lispro, insulin NPH, insulin NPH/regular, insulin regular]

isoniazidmonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

itraconazolecaution advised, monitor efficacy: combo may decr. antifungal levels, efficacy (hepatic metab. induced)

ketoconazolecaution advised, monitor phenytoin levels: combo may decr. antifungal levels, efficacy; incr. phenytoin levels, risk of toxicity (hepatic metab. altered)

lamotriginecaution advised, adjust lamotrigine initial dose escalation; adjust maint. dose if hydantoin added or stopped: combo may decr. lamotrigine levels by 40% (hepatic metab. induced)

lansoprazole/amoxicillin/clarithromycinmonitor phenytoin levels: combo may decr. clarithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown)

leflunomidemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

leucovorincaution advised, monitor levels: combo may decr. anticonvulsant levels, efficacy (mechanism unknown)

levoleucovorincaution advised, monitor levels: combo may decr. anticonvulsant levels, efficacy (mechanism unknown)

liraglutidemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

lithiummonitor levels: combo may incr. lithium levels, risk of toxicity (mechanism unknown)

magnesium hydroxide/mineral oilgive oral phenytoin 2h before or 4h after: combo w/ antacids may decr. phenytoin levels, efficacy (absorption decreased)

magnesium saltsgive oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)[magnesium salts: magnesium citrate, magnesium gluconate, magnesium oxide, magnesium sulfate]

maravirocadjust maraviroc dose to 600 mg bid, unless combined w/ hepatic metab. inhibitor requiring decr. maraviroc dose of 150 mg bid: combo may decr. maraviroc levels, efficacy (hepatic metab. induced)

mefloquinemonitor levels, efficacy: combo may decr. levels, efficacy of both drugs (mechanism unknown, hepatic metab. possibly altered)

metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

metformin/sulfonylurea combosmonitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects)[metformin/sulfonylurea combos: glipizide/metformin, glyburide/metformin]

methadonemonitor for efficacy, withdrawal: combo may decr. methadone levels, efficacy; precipitate opioid withdrawal symptoms (hepatic metab. induced)

methylphenidatemonitor levels: combo may incr. phenytoin levels, risk of toxicity; methylphenidate may lower seizure threshold (mechanism unknown, hepatic metab. possibly inhibited)[methylphenidate: dexmethylphenidate, methylphenidate, methylphenidate transdermal]

metronidazolemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

miglitolmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

modafinilmonitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects; may decr. armodafinil or modafinil levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)[modafinil: armodafinil, modafinil]

nateglinidemonitor glucose: combo may decr. nateglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

nelfinavirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

nitazoxanidemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

olanzapine/fluoxetinemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

omeprazolemonitor levels, esp. if omeprazole dose >20 mg/day: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)[omeprazole: omeprazole, omeprazole/sodium bicarbonate]

omeprazole/clarithromycin/amoxicillinmonitor phenytoin levels: combo w/ clarithromycin, omeprazole may incr phenytoin levels, risk of toxicity; combo may decr. clarithromycin levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

oxcarbazepinemonitor levels: combo may incr. phenytoin levels, risk of toxicity; decr. oxcarbazepine levels; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. altered; additive effects)

oxycodone/aspirincaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may decr. oxycodone levels, efficacy; incr. risk of CNS depression, psychomotor impairment; combo may incr. phenytoin levels, risk of toxicity (hepatic metab. induced; additive effects; protein binding displacement)

paroxetinemonitor phenytoin levels, monitor paroxetine efficacy: combo may incr. phenytoin levels, risk of toxicity; may decr. paroxetine levels, efficacy (hepatic metab. altered)

phenobarbitalmonitor levels: combo may decr. levels of both drugs (hepatic metab. induced)

phenobarbital/hyoscyamine/atropine/scopolaminemonitor levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

pioglitazonemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

pioglitazone/glimepiridemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

pioglitazone/metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

primidonemonitor levels: combo may incr. phenobarbital levels, decr. phenytoin levels (hepatic metab. induced; incr. conversion of primidone to phenobarbital)

propoxyphene/acetaminophencaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy; decr. propoxyphene levels, efficacy, incr. active metabolite formation, risk of toxicity; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced, incr. formation of toxic acetaminophen and propoxyphene metabolites; additive effects)[propoxyphene/acetaminophen: propoxyphene hydrochloride/acetaminophen, propoxyphene napsylate/acetaminophen]

quinidinemonitor levels: combo may decr. quinidine levels, efficacy (hepatic metab. induced)[quinidine: quinidine gluconate, quinidine sulfate]

repaglinidemonitor glucose: combo may decr. repaglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

repaglinide/metforminmonitor glucose: combo may decr. repaglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

rifampinsmonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)[rifampins: rifampin, rifampin/isoniazid, rifampin/isoniazid/pyrazinamide]

rifapentinemonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

ritonavirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

rosiglitazonemonitor glucose: combo may decr. rosiglitazone levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

rosiglitazone/glimepiridemonitor glucose: combo may decr. rosiglitazone levels; may decr. hypoglycemic agent efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

rosiglitazone/metforminmonitor glucose: combo may decr. rosiglitazone levels; may decr. hypoglycemic agent

efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

rufinamidemonitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects; decr. rufinamide levels, efficacy; incr. risk of CNS depression, psychomotor impairment (mechanism unknown; hepatic metab. induced; additive effects)

salicylates, non-acetylatedcaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)[salicylates, non-acetylated: bismuth subsalicylate, choline magnesium trisalicylate, magnesium salicylate, salsalate]

saquinavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

saxagliptinmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

saxagliptin/metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

sertralinemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown, hepatic metab. possibly inhibited)

sevelamergive anticonvulsant 1h before or 3h after, monitor efficacy: combo may decr. anticonvulsant levels, efficacy (absorption possibly decreased)

sitagliptinmonitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects)

sitagliptin/metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

sitagliptin/simvastatinmonitor statin efficacy; monitor glucose: combo may decr. statin levels, efficacy; may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (hepatic metab. induced; antagonistic effects)

statins, CYP3A4 substratesmonitor efficacy: combo may decr. statin levels, efficacy (hepatic metab. induced)[statins, CYP3A4 substrates: atorvastatin, ezetimibe/simvastatin, lovastatin, simvastatin]

sucralfategive oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)

sulfonylureasmonitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (hepatic metab. induced; antagonistic effects)[sulfonylureas: chlorpropamide, glimepiride, glipizide, glyburide, glyburide micronized, tolazamide, tolbutamide]

tacrolimusmonitor levels: combo may decr. tacrolimus levels, efficacy (hepatic metab. induced)

telithromycinmonitor phenytoin levels: combo may decr. telithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown)

tesamorelinmonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

theophyllinesmonitor levels: combo may decr. theophylline levels, efficacy (hepatic metab. induced)[theophyllines: aminophylline, theophylline]

thyroid hormonesmonitor thyroid function, adjust thyroid replacement dose if needed: combo may decr. thyroid hormone efficacy (hepatic metab. induced, clearance increased)[thyroid hormones: levothyroxine, liothyronine, liotrix, thyroid (porcine)]

tiagabinecaution advised; decr. tiagabine dose if other tx stopped or decreased: combo may incr. risk of CNS depression, psychomotor impairment; tiagabine dosing based on concomitant hepatic enzyme inducing drugs, levels may incr. >2x when induction removed (hepatic metab. induced, clearance incr. 60%; additive effects)

ticlopidinemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

tinidazolemonitor levels, efficacy: combo may incr. phenytoin levels, risk of toxicity; decr. tinidazole levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

tipranavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

TNF blocking agentsmonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. altered; TNF blockers may inhibit inflammatory cytokine-induced downregulation of CYP450 enzymes resulting in relative induction of enzymes upon tx start and downregulation upon D/C)[TNF blocking agents: adalimumab, certolizumab pegol, etanercept, golimumab, infliximab]

tocilizumabmonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. altered; tocilizumab may inhibit inflammatory cytokine-induced downregulation of CYP450 enzymes resulting in relative induction of enzymes upon tx start and downregulation upon D/C)

topiramatemonitor levels: combo may incr. phenytoin levels, risk of toxicity; decr. topiramate levels, efficacy (hepatic metab. altered)[topiramate: phentermine hydrochloride/topiramate, topiramate]

trazodonecaution advised, monitor phenytoin levels: combo may decr. trazodone levels, efficacy; may incr. phenytoin levels, risk of toxicity (hepatic metab. induced; mechanism unknown)

trimethoprimmonitor levels, CBC: combo may incr. phenytoin levels, risk of toxicity, risk of megaloblastic anemia (hepatic metab. inhibited, additive/synergistic folate antagonism)

trimethoprim/sulfamethoxazolemonitor levels, CBC: combo w/ trimethoprim may incr. phenytoin levels, risk of toxicity, risk of megaloblastic anemia (hepatic metab. inhibited, additive/synergistic folate antagonism)

ustekinumabmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. possibly altered; ustekinumab may normalize hepatic enzyme formation suppressed by incr. cytokine levels)

valacyclovirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown)

valproic acid derivativesmonitor levels; caution advised: combo may decr. valproic acid levels, efficacy; may incr. phenytoin levels, risk of toxicity; may incr. risk of CNS depression, psychomotor

impairment (hepatic metab. altered; additive effects)[valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid]

vigabatrinmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

voriconazoleincr. voriconazole dose per pkg insert; monitor phenytoin levels: combo may decr. antifungal levels, efficacy; incr. phenytoin levels, risk of toxicity (hepatic metab. induced; hepatic metab. inhibited)

warfarinmonitor INR: combo may decr. INR, warfarin efficacy and transiently incr. INR, risk of bleeding (hepatic metab. induced, protein binding displacement)

zafirlukastmonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

Caution Advised

abiraterone acetatecaution advised: combo may decr. abiraterone levels, efficacy (hepatic metab. induced)

aldesleukincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

alendronate/cholecalciferolcaution advised: combo may decr. cholecalciferol efficacy (hepatic metab. induced)

alfentanilcaution advised: combo may decr. alfentanil efficacy (hepatic metab. induced)

apomorphinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive/synergistic effects)

artemether/lumefantrinecaution advised: combo may decr. artemether/lumefantrine levels, efficacy (hepatic metab. induced)

azelastine nasalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal]

belataceptcaution advised: combo may decr. phenytoin levels, efficacy (hepatic metab. possibly

altered; belatacept may normalize hepatic enzyme formation suppressed by incr. cytokine levels)

benzocainecontraindicated if <1 yo, otherwise caution advised: combo w/ benzocaine may incr. risk of methemoglobinemia (additive effects)[benzocaine: benzalkonium chloride/benzocaine/zinc chloride oropharyngeal, benzethonium chloride/benzocaine topical, benzocaine oropharyngeal, benzocaine topical, benzocaine/allantoin/dimethicone/petrolatum topical, benzocaine/butamben/tetracaine topical, benzocaine/camphor/allantoin/dimethicone/petrolatum topical, benzocaine/camphor/allantoin/petrolatum topical, benzocaine/camphor/menthol/allantoin/dimethicone/petrolatum topical, benzocaine/glycerin oropharyngeal, benzocaine/menthol oropharyngeal, benzocaine/menthol topical, benzocaine/pectin oropharyngeal, benzocaine/petrolatum topical, benzocaine/zinc chloride oropharyngeal]

benzocaine/dextromethorphan comboscontraindicated if <1 yo, otherwise caution advised: combo w/ benzocaine may incr. risk of methemoglobinemia (additive effects)[benzocaine/dextromethorphan combos: benzocaine/dextromethorphan oropharyngeal, benzocaine/menthol/dextromethorphan oropharyngeal]

benzodiazepines, CYP3A4 substratescaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)[benzodiazepines, CYP3A4 substrates: alprazolam, midazolam, triazolam]

benzodiazepines, othercaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[benzodiazepines, other: clobazam, estazolam, lorazepam, oxazepam, temazepam]

black cohoshcaution advised: combo may incr. risk of hepatotoxicity (additive toxicity)[black cohosh: Actaea racemosa, baneberry, black cohosh (Actaea racemosa), black snakeroot, bugbane, bugwort, Cimicifuga racemosa, macrotys, rattle root, rattlesnake root, rattletop, rattleweed, squawroot]

bromocriptinecaution advised: combo may decr. bromocriptine levels, efficacy (hepatic metab. induced)

budesonidecaution advised: combo may decr. budesonide levels, efficacy (hepatic metab. induced)

buprenorphinecaution advised: combo may decr. buprenorphine levels, efficacy (hepatic metab.

induced)[buprenorphine: buprenorphine, buprenorphine transdermal, buprenorphine/naloxone]

bupropioncaution advised: combo may decr. buproprion efficacy (hepatic metab. induced)[bupropion: bupropion hydrobromide, bupropion hydrochloride]

buspironecaution advised: combo may decr. buspirone levels, efficacy (hepatic metab. induced)

busulfancaution advised: combo may decr. busulfan levels, efficacy (hepatic metab. induced)

caffeinecaution advised: combo may decr. caffeine levels, efficacy (hepatic metab. induced)[caffeine: caffeine, caffeine citrate, caffeine/sodium benzoate]

carbidopa/levodopacaution advised: combo may decr. levodopa efficacy (mechanism unknown)

carbidopa/levodopa/entacaponecaution advised: combo may decr. levodopa efficacy (mechanism unknown)

carbonic anhydrase inhibitors, systemiccaution advised: combo may incr. risk of osteomalacia (calcium renal excretion increased, metabolic acidosis)[carbonic anhydrase inhibitors, systemic: acetazolamide, methazolamide]

chlordiazepoxidecaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

clonazepamcaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

clorazepatecaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

colchicinecaution advised: combo may decr. colchicine levels, efficacy (hepatic metab. induced)

conivaptancaution advised: combo may decr. conivaptan levels, efficacy (hepatic metab. induced)

corticosteroids, systemiccaution advised: combo may decr. corticosteroid levels, efficacy (hepatic metab. induced)[corticosteroids, systemic: betamethasone sodium phosphate/betamethasone acetate, cortisone, dexamethasone, dexamethasone sodium phosphate, hydrocortisone,

hydrocortisone sodium succinate, methylprednisolone, methylprednisolone acetate, methylprednisolone sodium succinate, prednisolone, prednisone, triamcinolone acetonide]

cyclophosphamidecaution advised: combo may incr. cyclophosphamide active metabolite levels, risk of toxicity (hepatic metab. induced, incr. active metabolite formation)

dantrolenecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

dapsonecaution advised: combo may decr. dapsone levels, efficacy (hepatic metab. induced)

darifenacincaution advised: combo may decr. darifenacin levels, efficacy (hepatic metab. induced)

dasatinibcaution advised: combo may decr. dasatinib levels, efficacy (hepatic metab. induced)

diazoxidecaution advised: combo may incr. risk of hyperglycemia; combo w/ PO diazoxide may decr. phenytoin levels, incr. risk of seizures (additive effects; mechanism unknown)

diclofenaccaution advised: combo may decr. diclofenac levels, efficacy (hepatic metab. induced)[diclofenac: diclofenac potassium, diclofenac sodium, diclofenac/misoprostol]

docetaxelcaution advised: combo may decr. docetaxel levels, efficacy (hepatic metab. induced)

donepezilcaution advised: combo may decr. donepezil levels, efficacy (hepatic metab. induced)

doxercalciferolcaution advised: combo may decr. doxercalciferol efficacy (hepatic metab. induced)

doxycyclinecaution advised, monitor efficacy: combo may decr. doxycycline levels, efficacy (mechanism unknown)

eplerenonecaution advised: combo may decr. eplerenone levels, efficacy (hepatic metab. induced)

ergotamine/caffeinecaution advised: combo may decr. caffeine levels, efficacy (hepatic metab. induced)

eszopiclonecaution advised: combo may decr. eszopiclone levels, efficacy (hepatic metab. induced)

ethanolcaution advised: combo may incr. risk of CNS depression, alter phenytoin levels, incr. risk of seizures (additive effects, hepatic metab. induced w/ chronic and inhibited w/ acute alcohol use; alcohol withdrawal or excessive use may lower seizure threshold)

fentanylcaution advised: combo may decr. fentanyl levels, efficacy (hepatic metab. induced)[fentanyl: fentanyl, fentanyl nasal, fentanyl transdermal, fentanyl transmucosal]

flurazepamcaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

gabapentincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[gabapentin: gabapentin, gabapentin enacarbil]

green teacaution advised: combo may reduce effects of caffeine in green tea (hepatic metab. induced)[green tea: Camellia sinensis, Camellia thea, Chinese tea, green tea (Camellia sinensis), green tea extract, GTE, Japanese tea, Matsu-cha tea, Theaceae, theifers]

haloperidolcaution advised: combo may decr. haloperidol levels, efficacy (mechanism unknown)[haloperidol: haloperidol, haloperidol decanoate, haloperidol lactate]

HRT, estrogencaution advised: combo may result in loss of seizure control; combo may decr. estrogen levels, efficacy (estrogen-induced fluid retention; hepatic metab. induced)[HRT, estrogen: estradiol, estradiol acetate, estradiol cypionate, estradiol transdermal, estradiol vaginal, estradiol valerate, estrogens, conjugated, estrogens, conjugated (synthetic), estrogens, conjugated B (synthetic), estrogens, conjugated vaginal, estrogens, esterified, estrogens, esterified/methyltestosterone, estropipate]

HRT, estrogen/progestin combocaution advised: combo may result in loss of seizure control; combo may decr. estrogen, progestin levels, effica (estrogen-induced fluid retention; hepatic metab. induced)[HRT, estrogen/progestin combo: drospirenone/estradiol, estradiol/levonorgestrel transdermal, estradiol/norethindrone acetate, estradiol/norethindrone acetate transdermal, estradiol/norgestimate, estrogens, conjugated/medroxyprogesterone, norethindrone acetate/ethinyl estradiol]

HRT, progestincaution advised: combo may decr. progestin levels, efficacy (hepatic metab. induced)[HRT, progestin: medroxyprogesterone, norethindrone acetate]

hydromorphonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

hydroxyprogesterone (hormone replacement)caution advised: combo may decr. hydroxyprogesterone levels, efficacy (hepatic metab. induced)[hydroxyprogesterone (hormone replacement): hydroxyprogesterone]

ifosfamidecaution advised: combo may incr. ifosfamide active metabolite and toxic metabolite levels, incr. efficacy and risk of neurotoxicity (hepatic metab. induced, incr. active metabolite and toxic metabolite formation)

isotretinoincaution advised: combo may incr. risk of bone loss (additive effects)

kavacaution advised: combo may incr. risk of hepatotoxicity (additive toxicity)[kava: ava pepper, awa, intoxicating pepper, kao, kava (Piper methysticum), kawa, kew, Piper methysticum, sakau, tonga, yagona]

ketaminecaution advised: combo may decr. ketamine levels, efficacy (hepatic metab. induced)

levocetirizinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

levonorgestrel intrauterine devicecaution advised: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)

lidocaine topicalcontraindicated if <1 yo, otherwise caution advised: combo w/ topical lidocaine may incr. risk of methemoglobinemia (additive effects)[lidocaine topical: benzethonium chloride/lidocaine topical, hydrocortisone/lidocaine topical, lidocaine oronasopharyngeal, lidocaine topical, lidocaine urethral, lidocaine/epinephrine iontophoretic topical, lidocaine/prilocaine topical, lidocaine/tetracaine topical]

linezolidcaution advised: combo may decr. linezolid levels, efficacy (mechanism unknown, hepatic metab. possibly induced)

meperidinecaution advised: combo may decr. meperidine levels, analgesic efficacy, may incr. risk of normeperidine neurotoxicity (hepatic metab. induced, incr. toxic metabolite formation)

meprobamatecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

mirtazapinecaution advised: combo may decr. mirtazepine levels, effects (hepatic metab. induced)

mitotanecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

montelukastcaution advised: combo may decr. montelukast levels, efficacy (hepatic metab. induced)

morphine liposomalcaution advised: combo may incr. risk of CNS depression, profound sedation, hypotension, other adverse effects (additive effects)

nafarelin nasalcaution advised: combo may incr. risk of bone loss (additive effects)

nevirapinecaution advised: combo may decr. nevirapine levels, efficacy (hepatic metab. induced)

niacin/lovastatincaution advised: combo may decr. lovastatin levels, efficacy (hepatic metab. induced)

niacin/simvastatincaution advised: combo may decr. simvastatin levels, efficacy (hepatic metab. induced)

nitrites/sodium thiosulfatecaution advised: combo w/ nitrites may incr. risk of methemoglobinemia (additive effects)[nitrites/sodium thiosulfate: amyl nitrite/sodium nitrite/sodium thiosulfate, sodium nitrite/sodium thiosulfate]

nitroprussidecaution advised: combo may incr. risk of methemoglobinemia (additive effects)

olopatadine nasalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

oxycodonecaution advised, consider dose adjustment: combo may decr. oxycodone levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

oxycodone/ibuprofencaution advised, consider dose adjustment: combo may decr. oxycodone levels, efficacy;

incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

paclitaxelcaution advised: combo may decr. paclitaxel levels, efficacy (hepatic metab. induced)[paclitaxel: paclitaxel, paclitaxel nanoparticle albumin-bound]

peginterferon alfa 2bcaution advised: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

pimozidecaution advised: combo may decr. pimozide levels, efficacy; combo may incr. risk of CNS depression, psychomotor impairment; pimozide may lower seizure threshold (hepatic metab. induced; additive effects; antagonistic effects)

pramipexolecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

pregabalincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

progesterone (hormone replacement)caution advised: combo may decr. progesterone levels, efficacy (hepatic metab. induced)[progesterone (hormone replacement): progesterone micronized]

progesterone vaginal (hormone replacement)caution advised: combo may decr. progesterone levels, efficacy (hepatic metab. induced)[progesterone vaginal (hormone replacement): progesterone vaginal]

propofolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment; may decr. propofol levels, efficacy (additive effects; hepatic metab. induced)[propofol: fospropofol, propofol]

propoxyphenecaution advised: combo may decr. propoxyphene levels, efficacy, incr. active metabolite formation, risk of toxicity (hepatic metab. induced)[propoxyphene: propoxyphene hydrochloride, propoxyphene napsylate]

quetiapinecaution advised: combo may decr. quetiapine levels, efficacy (clearance increased)

quinine sulfatecaution advised: combo may decr. quinine levels, efficacy (hepatic metab. induced)

ramelteoncaution advised: combo may decr. ramelteon levels, efficacy (hepatic metab. induced)

risperidonecaution advised: combo may decr. risperidone levels, efficacy (hepatic metab. induced)

romidepsincaution advised: combo may decr. romidepsin levels, efficacy (hepatic metab. induced)

ropinirolecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

rotigotine transdermalcaution advised: combo may incr. phenytoin levels, risk of toxicity; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. inhibited; additive effects)

ruxolitinibcaution advised: combo may decr. ruxolitinib levels, efficacy, may incr. active metabolite formation, risk of adverse effects (hepatic metab. induced)

selegilinecaution advised: combo may decr. selegiline levels, efficacy (hepatic metab. induced)

selegiline transdermalcaution advised: combo may decr. selegiline levels, efficacy (hepatic metab. induced)

sildenafilcaution advised: combo may decr. sildenafil levels, efficacy (hepatic metab. induced)

sodium oxybatecaution advised: combo may incr. risk of CNS depression, other adverse effects (additive effects)

solifenacincaution advised: combo may decr. solifenacin levels, efficacy (hepatic metab. induced)

sorafenibcaution advised, monitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects; decr. sorafenib levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

streptozocincaution advised: combo may decr. streptozocin efficacy (mechanism unknown)

sufentanilcaution advised: combo may decr. sufentanil efficacy (hepatic metab. induced)

tamoxifencaution advised: combo may decr. tamoxifen and active metabolite levels, efficacy (hepatic metab. induced)

tapentadolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

teniposidecaution advised: combo may decr. teniposide levels, efficacy (hepatic metab. induced)

tetrabenazinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

thiotepacaution advised: combo may decr. thiotepa levels, efficacy; may incr. thiotepa active metabolite levels, risk of toxicity (hepatic metab. induced)

toremifenecaution advised: combo may decr. toremifene levels, efficacy (hepatic metab. induced)

tricyclic antidepressantscaution advised: combo w/ TCAs may alter seizure control; combo may incr. risk of CNS depression, psychomotor impairment (decreased seizure threshold; additive effects)[tricyclic antidepressants: amitriptyline, amoxapine, chlordiazepoxide/amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, perphenazine/amitriptyline, protriptyline, trimipramine]

vemurafenibcaution advised: combo may decr. vemurafenib levels, efficacy (hepatic metab. induced)

vinca alkaloidscaution advised: combo may decr. vinca alkaloid levels, efficacy (hepatic metab. induced)[vinca alkaloids: vinblastine, vincristine, vinorelbine]

zaleploncaution advised: combo may decr. zaleplon levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

zolpidemcaution advised: combo may decr. zolpidem levels, efficacy (hepatic metab. induced)

zonisamidecaution advised: combo may decr. zonisamide levels, efficacy (hepatic metab. induced)

Adverse Reactions

Serious Reactions

ventricular fibrillation (IV use) hypotension, severe (IV use)

cardiovascular collapse (IV use)

AV conduction abnormalities (IV use)

hepatotoxicity

thrombocytopenia

leukopenia

agranulocytosis

pancytopenia

anemia, megaloblastic

exfoliative dermatitis

Stevens-Johnson syndrome

toxic epidermal necrolysis

rash w/ eosinophilia and systemic sx

tissue necrosis (IV use)

purple glove syndrome (IV use)

anaphylaxis

lymphoma

lupus erythematosus

osteomalacia

toxic delirium

suicidality

periarteritis nodosa

Common Reactions

nausea vomiting

rash

nystagmus

ataxia

slurred speech

dizziness

confusion

paresthesia

blurred vision

somnolence

constipation

headache

insomnia

gingival hyperplasia

taste changes

tremor

lymphadenopathy

coarse facies

hyperglycemia

osteomalacia

phlebitis (IV use)

Peyronie dz

Safety/Monitoring

Pregnancy: D (Positive evidence of human fetal risk; maternal benefit may outweigh fetal risk in serious or life-threatening situations; see pkg insert for drug-specific recs)

Lactation: Probably Safe (Limited information in animals and/or humans demonstrates no risk/minimal risk of adverse effects to infant/breast milk production; caution advised)

Therapeutic Drug Levels 10-20 mcg/mL (total), 1-2 mcg/mL (free); Toxic Levels: >20 mcg/mL (total), >2 mcg/mL (free); Timing: 2-4h after IV load, 24h after PO load, or just prior to next dose; Time to Steady State: 7-10 days, highly variable

Monitoring Parameters Cr at baseline; CBC; LFTs; folate; serum drug levels periodically and if change dosage form/brand; dental exam q3mo; s/sx depression, behavior changes, suicidality

Look/Sound-Alike Drug Names [from www.usp.org]

Dilantin confused with: Diflucan; Dilaudid; diltiazem; Neurontin; nystatin

phenytoin confused with: phenylephrine

phenytoin sodium confused with: Feldene; fluconazole; fosphenytoin; nystatin; phenazopyridine; phenobarbital; phytonadione

Pharmacology

Metabolism: liver; CYP450: 2C9 (primary), 2C19 substrate; 2B6, 2C9/19, 3A4 inducer

Excretion: bile, urine; Half-life: 22h

Subclass: Seizure Disorders

Mechanism of Actionmodulates neuronal voltage-dependent sodium and calcium channels

Manufacturer/Pricing

Manufacturer: Pfizer Inc.

DEA/FDA: Rx: (Requires prescription; not a controlled substance)

Approximate Retail Price

from  www.drugstore.com

capsule:

30 mg (90 ea): $54.99 100 mg (90 ea): $58.99

tablet, chewable:

50 mg (90 ea): $63.99

Patient Education

Nombre Genérico: phenytoin (oral)

Nombres de las Marcas: Dilantin, Dilantin Infatabs, Dilantin-125, Phenytek

¿Cuál es la información más importante que debo saber sobre phenytoin?

Usted no debe tomar phenytoin si usted también está tomando delavirdine (Rescriptor), o si es alérgico a phenytoin, ethotoin (Peganone), fosphenytoin (Cerebyx), o mephenytoin (Mesantoin).

Si usted está embarazada, NO EMPIECE A TOMAR phenytoin salvo que su médico le haya indicado hacerlo. Phenytoin puede hacer daño al bebé nonato, pero tener una convulsión cuando está embarazada le puede hacer daño a la madre y al bebé. Si usted queda embarazada mientras está tomando phenytoin, NO DEJE DE TOMAR la medicina sin el consejo de su médico. Control de las convulsiones es muy importante durante el embarazo y el beneficio de evitar convulsiones puede sobrepasar el riesgo que presenta tomar phenytoin.

Usted puede tener pensamientos de suicidio cuando empiece a tomar esta medicina. Su médico necesitará examinarlo con regularidad. No falte a las visitas médica establecidas por su médico.

Informe a su médico de algún síntoma nuevo o que empeora, como: cambios del humor o del comportamiento, depresión, ansiedad, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o de físico), o tiene pensamientos de suicidio o de querer hacerse daño.

¿Qué es phenytoin?

Phenytoin es una droga antiepiléptica, también conocida como un anticonvulsivante. Funciona reduciendo los impulsos en el cerebro que causan convulsiones.

Phenytoin se usa para el control de las convulsiones. Phenytoin no trata todas los tipos de convulsiones, y su médico determinará si es la medicina correcta para usted.

Phenytoin puede también usarse para fines no mencionados en esta guía del medicamento.

¿Qué debería discutir con el profesional del cuidado de la salud antes de usar phenytoin?

Usted no debe tomar phenytoin si usted también está tomando delavirdine (Rescriptor), o si es alérgico a phenytoin, ethotoin (Peganone), fosphenytoin (Cerebyx), o mephenytoin (Mesantoin).

Para asegurarse que usted puede tomar phenytoin de forma segura, dígale a su médico si usted tiene cualquiera de estas otras condiciones:

enfermedad del hígado; lupus;

diabetes;

deficiencia de la vitamina D o cualquier otra condición que desgasta los huesos;

porfiria (un trastorno genético de enzima que causa síntomas que afectan la piel o el sistema nervioso); o

si usted consume gran cantidad de alcohol.

Usted puede tener pensamientos de suicidio mientras toma este medicamento. Dígale a su médico si usted tiene síntomas de la depresión o pensamientos de suicidio nuevos o que empeoran durante los primeros meses del tratamiento, o cuando tenga cambios en su dosis.

Su familia o quienes lo atiendan también deben mantenerse alertas a los cambios en su humor o síntomas. Su médico necesitará examinarlo con regularidad. No falte a las visitas médicas establecidas por su médico.

Los pacientes con antepasados de origen Asiático pueden tener un riesgo más alto de desarrollar una reacción a la piel, rara, pero de gravedad con phenytoin. Su médico puede recomendar pruebas de la sangre antes de que empiece la medicina para determinar su riesgo a tener esta reacción.

Categoría D del embarazo por la FDA. Phenytoin le puede hacer daño al bebé nonato, pero tener una convulsión cuando está embarazada le puede hacer daño a la madre y al bebé.

Si usted está embarazada, NO EMPIECE A TOMAR phenytoin salvo que su médico le haya indicado. Si usted queda embarazada mientras está tomando phenytoin, NO DEJE DE TOMAR la medicina sin el consejo de su médico.

El control de las convulsiones es muy importante durante el embarazo. El beneficio de evitar convulsiones puede sobrepasar el riesgo que presenta tomar phenytoin. Siga las instrucciones de su médico acerca de tomar phenytoin durante su embarazo.

Phenytoin puede hacer las pastillas anticonceptivas menos efectivas. Para prevenir el embarazo mientras toma phenytoin, use un método de control de natalidad no hormonal (como el condón o diafragma con espermicida).

Phenytoin puede pasar a la leche materna y causarle daño al bebé lactante. Usted no debe amamantar mientras está usando phenytoin.

¿Cómo debo tomar phenytoin?

Tómelo exactamente cómo lo haya recetado su médico. No lo tome en cantidades mayores o menores, o por más tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripción.

No triture, mastique, rompa, o abra una cápsula de liberación extendida. Tráguelas enteras. Romper o abrir la píldora puede causar que mucha medicina pase al cuerpo de inmediato. No use ninguna cápsula que ha cambiado de color. Llame a su médico para una nueva prescripción.

Agite bien la suspensión oral (líquida) antes de medir una dosis. Mida el líquido con una cucharita o taza de medición, no lo haga con una cuchara normal. Si no tiene con que medir su dosis, pídale una a su farmacéutico.

Para estar seguro de que este medicamento está ayudando su condición, tal vez se necesite examinar su sangre con frecuencia. También puede ser que necesite exámenes de sangre cuando cambie de una presentación de phenytoin a otra. Visite a su médico con regularidad.

Si está tomando phenytoin para el tratamiento de convulsiones, siga tomando la medicina aunque se sienta bien. Usted puede tener un aumento en convulsiones si deja de tomar phenytoin. No cambie su dosis de phenytoin sin la previa aprobación de su médico. Dígale a su médico si le parece que su medicina ha dejado de funcionar como lo hacia para el tratamiento de su condición.

Lleve con usted una tarjeta de identificación que indique que usted está tomando phenytoin. Cualquier proveedor del cuidado médico que lo trate debería saber que usted esta usando una medicina para el control de convulsiones.

Guarde a temperatura ambiente lejos de la humedad, luz, y calor.

¿Qué sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sáltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome más medicina para alcanzar la dosis pasada.

¿Qué sucedería en una sobredosis?

Busque atención médica de emergencia o llame a la línea de Poison Help al 1-800-222-1222. La sobredosis de phenytoin puede ser fatal. Los síntomas de sobredosis pueden incluir movimientos espasmódicos de los ojos, arrastre de las palabras al hablar, perdida del balance, temblores, rigidez muscular o debilidad, náusea, vómito, sentir que se puede desmayar, desmayo, y respiración lenta o no profunda.

¿Qué debo evitar mientras uso phenytoin?

Evite beber alcohol mientras esté tomando phenytoin. Consumir alcohol puede aumentar sus niveles de phenytoin en la sangre y puede aumentar los efectos secundarios. Consumir alcohol diariamente puede disminuir sus niveles de phenytoin en la sangre, lo que puede aumentar su riesgo de convulsiones.

Evite tomar antiácidos al mismo tiempo que toma phenytoin. Los antiácidos pueden hacer más difícil para que su cuerpo pueda absorber la medicina.

Phenytoin puede perjudicar su pensamiento o reacciones. Tenga cuidado si usted conduce un vehículo o tenga que hacer algo que demande se mantenga alerta.

¿Cuáles son los efectos secundarios posibles de phenytoin?

Busque atención médica de emergencia si usted tiene alguno de estos síntomas de una reacción alérgica: ronchas; dificultad para respirar; hinchazón de su cara, labios, lengua, o garganta. Es más probable que tenga una reacción alérgica si es de raza Americana-Africana.

Informe a su médico de algún síntoma nuevo o que empeora, como: cambios del humor o del comportamiento, depresión, ansiedad, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o de físico), o tiene pensamientos de suicidio o de querer hacerse daño.

Llame a su médico de inmediato si usted tiene un efecto secundario grave como:

fiebre, glándulas hinchadas, dolor de cuerpo, síntomas de la gripe;

sarpullido, moretones o sangrado fácil, hormigueo severo, entumecimiento, dolor, debilidad muscular;

dolor en la parte superior del estómago, pérdida del apetito, orina oscura, ictericia (color amarillo de la piel u ojos);

dolor de pecho, ritmo cardíaco irregular, sensación de que le falta aire al respirar;

confusión, náusea y vómito, hinchazón, ganancia de peso rápida, orinar menos de lo usual o nada en absoluto;

tos nueva o que empeora con fiebre, dificultad para respirar;

temblor (sacudidas que no puede controlar), movimientos musculares inquietos en sus ojos, lengua, quijada, o cuello;

color de piel con parches, manchas rojas, o un sarpullido en forma de mariposa sobre sus mejillas y nariz (que empeora con la luz del sol); o

reacción severa de la piel -- fiebre, dolor de garganta, hinchazón en su cara o lengua, quemazón en sus ojos, dolor de la piel, seguido por un sarpullido rojo o púrpura que se extiende (especialmente en la cara o la parte superior del cuerpo) y causa ampollas y descamación.

Efectos secundarios de menor gravedad pueden incluir:

habla arrastrado, perdida del balance o coordinación; encías hinchadas o adoloridas; o

dolor de cabeza, nerviosismo, o problemas para dormir (insomnio).

Esta lista no menciona todos los efectos secundarios y puede ser que ocurran otros. Llame a su médico para consejos médicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

¿Qué otras drogas afectarán a phenytoin?

Varias drogas pueden tener interacciones con phenytoin. La lista que se presenta abajo no incluye todas las drogas. Dígale a su médico si usted está usando:

antibióticos como cycloserine (Seromycin), doxycycline (Doryx, Vibramycin, Adoxa), isoniazid (para tratar tuberculosis), linezolid (Zyvox), rifampin (Rimactane, Rifadin, Rifamate), o sulfas (Bactrim, Septra, Sulfatrim, SMX-TMP, y otras);

un antidepresivo (como Elavil, Vanatrip, Limbitrol, Sinequan, Silenor, Pamelor, Paxil, Zoloft, Desyrel, y otras);

aspirin u otros salicilatos;

pastillas para el control de la natalidad o terapia de reemplazo hormonal;

un anticoagulante como warfarin (Coumadin, Jantoven);

ciertos sedantes (Librium, Librax, Limbitrol, Valium) o antidepresivos (Desyrel, Luvox, Zoloft, Prozac, Rapiflux, Sarafem, Selfemra, Symbyax);

medicamento para el corazón como amiodarone (Cordarone, Pacerone), digoxin (digitalis, Lanoxin), furosemide (Lasix), o quinidine (Quin-G);

prochlorperazine (Compazine, Compro), promethazine (Pentazine, Phenergan, Anergan, Antinaus), y otras fenotiazinas;

esteroides (prednisone y otras);

medicamento para convulsiones (como Carbatrol, Equetro, Tegretol, Solfoton, Depakene, o Depakote);

medicinas para reducir el ácido del estómago (como Tagamet, Prilosec, Zegerid, Zantac, Pepcid, o Axid; o

theophylline (Elixophyllin, Theo-Dur, Theo-Bid, Theolair, Uniphyl).

Esta lista no incluye todas las drogas y hay muchas otras drogas que pueden tener interacciones con phenytoin. Dígale a su médico acerca de todas los medicamentos que usted usa. Incluya los productos que se obtienen con o sin receta, vitaminas, y productos herbarios. No empiece un nuevo medicamento sin primero decirle a su médico. Mantenga una lista de todas sus medicinas y muéstresela a cualquier profesional de la salud que lo atienda.

¿Dónde puedo obtener más información?

Su farmacéutico le puede dar más información acerca de phenytoin.

Drug

Gralisegabapentin

Entire Monograph

Adult Dosing

Dosage forms:  300,600 ER

post-herpetic neuralgia

[1800 mg PO qd]Start: 300 mg PO qd x1 day, then 600 mg PO qd x1 day, then incr. by 300 mg/day q4 days; Max: 1800 mg/day; Info: give w/ evening meal; do not cut/crush/chew; taper dose gradually over >7 days to D/C

renal dosing

[adjust dose amount]CrCl 30-60: start 300 mg qd, may incr. to 600-1800 mg qd; CrCl <30: avoid use; HD: avoid use

hepatic dosing

[no adjustment]

Peds Dosing

Peds dosing is currently unavailable or not applicable for this drug.

Contraindications/Cautions

hypersens. to drug/class/compon. avoid abrupt withdrawal

caution if renal impairment

caution if depression or hx

caution if CNS depressant use

caution if alcohol use

caution if drug abuse hx

Drug Interactions

Avoid/Use Alternative

ginkgo bilobaavoid consumption of raw ginkgo seeds: combo may decr. anticonvulsant efficacy (antagonistic effects, high dose ginkgotoxin may cause seizures)[ginkgo biloba: Eun-haeng, fossil tree, ginkgo (Ginkgo biloba), Ginkgo biloba, ginkyo, icho, ityo, Japanese silver apricot, kew tree, maidenhair tree, salisburia, silver apricot]

Monitor/Modify Tx

antacidsgive gabapentin 2h after antacid: combo may decr. gabapentin efficacy (absorption decreased)[antacids: aluminum hydroxide, aluminum hydroxide/magnesium carbonate, aluminum hydroxide/magnesium hydroxide, aluminum hydroxide/magnesium hydroxide/simethicone, aluminum hydroxide/magnesium trisilicate, magnesium hydroxide]

aspirin/calcium carbonategive gabapentin 2h after oral calcium: combo may decr. gabapentin efficacy (absorption decreased via chelation)

calcium carbonate/magnesium hydroxidegive gabapentin 2h after antacid: combo may decr. gabapentin efficacy (absorption decreased via chelation)[calcium carbonate/magnesium hydroxide: calcium carbonate/magnesium hydroxide, calcium carbonate/magnesium hydroxide/simethicone]

calcium saltsgive gabapentin 2h after oral calcium: combo may decr. gabapentin efficacy (absorption decreased via chelation)[calcium salts: calcium acetate, calcium carbonate, calcium carbonate/simethicone, calcium chloride, calcium citrate, calcium gluconate, risedronate/calcium carbonate]

famotidine/calcium carbonate/magnesium hydroxidegive gabapentin 2h after: combo may decr. gabapentin efficacy (absorption decreased via chelation)

iron salts, oralgive gabapentin 2h after iron: combo may decr. gabapentin efficacy (absorption

decreased via chelation)[iron salts, oral: ferrous gluconate, ferrous sulfate]

magnesium hydroxide/mineral oilgive gabapentin 2h after antacid: combo may decr. gabapentin efficacy (absorption decreased)

magnesium saltsgive gabapentin 2h after oral magnesium: combo may decr. gabapentin efficacy (absorption decreased via chelation)[magnesium salts: magnesium citrate, magnesium gluconate, magnesium oxide, magnesium sulfate]

methadonecaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

sevelamergive anticonvulsant 1h before or 3h after, monitor efficacy: combo may decr. anticonvulsant levels, efficacy (absorption possibly decreased)

Caution Advised

acetaminophen/caffeine/CNS depressant comboscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[acetaminophen/caffeine/CNS depressant combos: acetaminophen/caffeine/dihydrocodeine, butalbital/acetaminophen/caffeine, butalbital/acetaminophen/caffeine/codeine]

acetaminophen/chlorpheniraminecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

acetaminophen/chlorpheniramine/dextromethorphancaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

acetaminophen/chlorpheniramine/dextromethorphan/phenylephrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

acetaminophen/chlorpheniramine/phenylephrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

acetaminophen/codeinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

acetaminophen/diphenhydraminecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

acetaminophen/diphenhydramine/dextromethorphancaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

acetaminophen/diphenhydramine/phenylephrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

acetaminophen/doxylamine/dextromethorphancaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

acetaminophen/doxylamine/dextromethorphan/phenylephrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

acetaminophen/doxylamine/dextromethorphan/pseudoephedrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

acetaminophen/doxylamine/phenylephrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

acetaminophen/pheniramine/phenylephrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

aldesleukincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

alfentanilcaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

antidepressants, othercaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[antidepressants, other: maprotiline, mirtazapine, nefazodone, trazodone]

antihistamine/decongestant comboscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[antihistamine/decongestant combos: acrivastine/pseudoephedrine,

brompheniramine/phenylephrine, chlorpheniramine/phenylephrine, chlorpheniramine/pseudoephedrine, diphenhydramine/phenylephrine]

antihistamines, sedatingcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[antihistamines, sedating: brompheniramine, carbinoxamine, chlorpheniramine, clemastine, cyclizine, cyproheptadine, dexchlorpheniramine, dimenhydrinate, diphenhydramine, doxylamine, hydroxyzine, meclizine, triprolidine]

antipsychoticscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[antipsychotics: aripiprazole, asenapine, clozapine, haloperidol, haloperidol decanoate, haloperidol lactate, iloperidone, loxapine, lurasidone, olanzapine, paliperidone, paliperidone palmitate, quetiapine, risperidone, thiothixene, ziprasidone]

apomorphinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

aspirin/chlorpheniramine/dextromethorphancaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

aspirin/chlorpheniramine/dextromethorphan/phenylephrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

aspirin/chlorpheniramine/phenylephrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

aspirin/diphenhydraminecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

aspirin/doxylamine/dextromethorphan/phenylephrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

azelastine nasalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal]

barbituratescaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

[barbiturates: butabarbital, methohexital, pentobarbital, phenobarbital, primidone, secobarbital, thiopental]

benzodiazepines, allcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[benzodiazepines, all: alprazolam, chlordiazepoxide, clobazam, clonazepam, clorazepate, diazepam, diazepam rectal, estazolam, flurazepam, lorazepam, midazolam, oxazepam, temazepam, triazolam]

brompheniramine/dextromethorphan/phenylephrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

brompheniramine/dextromethorphan/pseudoephedrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

butalbital/acetaminophencaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

calendulacaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[calendula: bride of the sun, calendula (Calendula officinalis), Calendula officinalis, garden marigold, gold-bloom, golden flower of Mary, holligold, marigold, marybud, pot marigold]

cannabinoidscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[cannabinoids: dronabinol, nabilone]

capsicumcaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[capsicum: African chilies, capsaicin, capsicum (Capsicum annuum), Capsicum annuum, cayenne, chili pepper, green chili pepper, Louisiana long pepper, Mexican chilies, paprika, pimento, red pepper, tabasco pepper]

carbamazepinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

carisoprodol/aspirincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

central alpha 2 agonistscaution advised: combo may incr. risk of CNS depression, psychomotor impairment

(additive effects)[central alpha 2 agonists: clonidine, clonidine transdermal, guanabenz, guanfacine, methyldopa]

cetirizinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

cetirizine/pseudoephedrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

chamomile, Germancaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[chamomile, German: chamomile, German (Matricaria recutita), chamomile, Hungarian, chamomile, wild, Chamomilla recutita, Matricaria chamomilla, Matricaria recutita, pin heads]

chlorpheniramine/dextromethorphancaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

chlorpheniramine/dextromethorphan/pseudoephedrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

CNS depressant/aspirin/caffeine comboscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[CNS depressant/aspirin/caffeine combos: butalbital/aspirin/caffeine, butalbital/aspirin/caffeine/codeine, dihydrocodeine/aspirin/caffeine]

codeinecaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[codeine: codeine phosphate, codeine sulfate]

codeine/guaifenesincaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

dantrolenecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

dexmedetomidinecaution advised, consider dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

doxylamine/dextromethorphancaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

droperidolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

ethanolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects; alcohol withdrawal or excessive use may lower seizure threshold)

ethosuximidecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

etomidatecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

ezogabinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

fentanylcaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[fentanyl: fentanyl, fentanyl nasal, fentanyl transdermal, fentanyl transmucosal]

ginseng, Siberiancaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[ginseng, Siberian: Acanthopanax senticosus, devil's bush, eleuthero, eleutherococcus, Eleutherococcus senticosus, ginseng, Siberian (Eleutherococcus senticosus), shigoka, thorny pepperbush, Touch-Me-Not, untouchable, wild pepper]

goldensealcaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[goldenseal: berberine, eye balm, eye root, goldenseal (Hydrastis canadensis), ground raspberry, Hydrastis canadensis, Indian plant, jaundice root, orange root, wild curcuma, yellow root]

gotu kolacaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[gotu kola: brahma-buti, Centella asiatica, gotu kola (Centella asiatica), hydrocotyle, Indian pennywort, Indian water navelwort, madescassol, marsh penny, talepetrako, thick-leaved pennywort, white rot]

hawthorncaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)

[hawthorn: aubepine, Chinese hawthorn, Crataegus laevigata, Crataegus monogyna, Crataegus oxyacantha, Crataegus pentagyna, English hawthorn, hawthorn (Crataegus spp.), hedgethorn, maybush, maythorn, oneseed hawthorn, shanzha, whitehorn]

hydrocodonescaution advised w/ high doses of gabapentin, consider opioid dose reduction: combo may decr. hydrocodone levels, efficacy; incr. risk of CNS depression, psychomotor impairment (mechanism unknown; additive effects)[hydrocodones: chlorpheniramine/hydrocodone, hydrocodone/acetaminophen, hydrocodone/chlorpheniramine/pseudoephedrine, hydrocodone/homatropine, hydrocodone/ibuprofen, hydrocodone/pseudoephedrine]

hydromorphonecaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

inhaled anestheticscaution advised, consider dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[inhaled anesthetics: desflurane, enflurane, isoflurane, sevoflurane]

kavacaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[kava: ava pepper, awa, intoxicating pepper, kao, kava (Piper methysticum), kawa, kew, Piper methysticum, sakau, tonga, yagona]

ketaminecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

lemon balmcaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[lemon balm: balm, bee balm, cure-all, dropsy plant, honey plant, lemon balm (Melissa officinalis), Melissa, Melissa folium, Melissa officinalis, sweet balm, sweet Mary]

levocetirizinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

levorphanolcaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

meperidinecaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

meprobamatecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

metoclopramidecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

mitotanecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

morphinecaution advised: combo may incr. gabapentin levels, risk of somnolence, other adverse effects; incr. analgesic effects of morphine (absorption increased, clearance decreased; additive effects)[morphine: morphine sulfate, morphine sulfate/naltrexone]

morphine liposomalcaution advised: combo may incr. gabapentin levels, risk of somnolence, other adverse effects; incr. analgesic effects of morphine (absorption increased, clearance decreased; additive effects)

muscle relaxantscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[muscle relaxants: baclofen, baclofen intrathecal, carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine, tizanidine]

naproxencaution advised: combo may incr. gabapentin levels, risk of somnolence, other adverse effects (mechanism unknown)[naproxen: naproxen, naproxen sodium]

naproxen/esomeprazolecaution advised: combo w/ naproxen may incr. gabapentin levels, risk of somnolence, other adverse effects (mechanism unknown)

NSAID/chlorpheniramine/pseudoephedrine comboscaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)[NSAID/chlorpheniramine/pseudoephedrine combos: ibuprofen/chlorpheniramine/pseudoephedrine]

NSAID/diphenhydramine comboscaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)[NSAID/diphenhydramine combos: ibuprofen/diphenhydramine]

olanzapine/fluoxetinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

olopatadine nasalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

opiate agonist/antagonistscaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[opiate agonist/antagonists: buprenorphine, buprenorphine transdermal, buprenorphine/naloxone, butorphanol, butorphanol nasal, nalbuphine, pentazocine lactate, pentazocine/naloxone]

opiate/aspirin comboscaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[opiate/aspirin combos: carisoprodol/aspirin/codeine, oxycodone/aspirin]

oxcarbazepinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

oxycodonecaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

oxycodone/acetaminophencaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

oxycodone/ibuprofencaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

oxymorphonecaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

passionflowercaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[passionflower: apricot vine, corona de cristo, Fleischfarbige, fleur de la passion, maypop, Passiflora incarnata, passion vine, passionflower (Passiflora incarnata), purple passion flower, water lemon, wild passion flower]

pentazocine/acetaminophencaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

pheniramine/dextromethorphan/phenylephrinecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

phenobarbital/hyoscyamine/atropine/scopolaminecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

phenothiazinescaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[phenothiazines: chlorpromazine, fluphenazine, fluphenazine decanoate, perphenazine, prochlorperazine edisylate, prochlorperazine maleate, prochlorperazine rectal, promethazine, promethazine rectal, thioridazine, trifluoperazine]

phenytoinscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[phenytoins: fosphenytoin, phenytoin]

pimozidecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

pramipexolecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

pregabalincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

promethazine/codeinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

propofolcaution advised, consider dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[propofol: fospropofol, propofol]

remifentanilcaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

ropinirolecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

rotigotine transdermalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

rufinamidecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

sedative/hypnoticscaution advised, consider sedative/hypnotic dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[sedative/hypnotics: chloral hydrate, eszopiclone, zaleplon, zolpidem]

sodium oxybatecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

sufentanilcaution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

sumatriptan/naproxen sodiumcaution advised: combo w/ NSAIDs may incr. gabapentin levels, risk of somnolence, other adverse effects (mechanism unknown)

tapentadolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

tetrabenazinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

thalidomidecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

tiagabinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

topiramatecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[topiramate: phentermine hydrochloride/topiramate, topiramate]

tramadolcaution advised, especially in non-epileptic pts: combo may incr. risk of CNS depression,

psychomotor impairment, seizures (additive effects; seizure threshold lowered by tramadol)

tramadol/acetaminophencaution advised, especially in non-epileptic pts: combo may incr. risk of CNS depression, psychomotor impairment, seizures (additive effects; seizure threshold lowered by tramadol)

tricyclic antidepressantscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[tricyclic antidepressants: amitriptyline, amoxapine, chlordiazepoxide/amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, perphenazine/amitriptyline, protriptyline, trimipramine]

valeriancaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[valerian: all-heal, amantilla, baldrian, baldrianwurzel, garden heliotrope, herba benedicta, valerian (Valeriana officinalis), Valeriana edulis, Valeriana jatamansii, Valeriana officinalis, Valeriana sitchensis, Valeriana wallichii]

valproic acid derivativescaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid]

vigabatrincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

ziconotide intrathecalcaution advised: combo may incr. risk of confusion, dizziness, other CNS adverse effects (additive effects)[ziconotide intrathecal: ziconotide]

zonisamidecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

Adverse Reactions

Serious Reactions

leukopenia thrombocytopenia

dyskinesia

depression

suicidality

hostility

erythema multiforme

Stevens-Johnson syndrome

rash w/ eosinophilia and systemic sx

angioedema

acute renal failure

seizures if abrupt D/C

withdrawal sx if abrupt D/C

Common Reactions

dizziness somnolence

ataxia

fatigue

peripheral edema

nystagmus

nausea/vomiting

viral infection

fever

hostility

tremor

emotional lability

blurred vision

asthenia

diarrhea

infection

xerostomia

hyperkinesia

headache

constipation

URI

abnormal thinking

dysarthria

dyspepsia

weight gain

Safety/Monitoring

Pregnancy: C (Animal studies show adverse fetal effect(s) but no controlled human studies OR no animal or human studies; weigh possible fetal risk vs. maternal benefit; see pkg insert for drug-specific recs)

Lactation: Probably Safe (Limited information in animals and/or humans demonstrates no risk/minimal risk of adverse effects to infant/breast milk production; caution advised)

Monitoring Parameters Cr at baseline; s/sx depression, behavior changes, suicidality

Avoid Abrupt Cessation taper dose gradually over >7 days to D/C (abrupt cessation of gabapentin may cause anxiety, insomnia, nausea, pain, sweating; incr. seizure frequency may occur in pts w/ seizure disorder)

Look/Sound-Alike Drug Names [from www.usp.org]

gabapentin confused with: gatifloxacin; gemfibrozil; guaifenesin

Pharmacology

Metabolism: none; CYP450: none

Excretion: urine (100% unchanged); Half-life: 5-7h

Subclass: Other Neurologics

Mechanism of Actionexact mechanism of action unknown

Manufacturer/Pricing

Manufacturer: Depomed, Inc.

DEA/FDA: Rx: (Requires prescription; not a controlled substance)

Approximate Retail Price

from  www.drugstore.com

This information is currently not available for this drug.

Patient Education

Nombre Genérico: gabapentin

Nombres de las Marcas: Gralise, Horizant, Neurontin

¿Cuál es la información más importante que debo saber sobre gabapentin?

Usted no debe usar esta medicina si es alérgico a gabapentin.

Antes de tomar gabapentin, dígale a su médico si usted tiene enfermedad de los riñones, del hígado, o enfermedad del corazón.

Usted puede tener pensamientos de suicidio mientras esté tomando gabapentin. Su médico necesitará chequearlo con regularidad. No falta a ninguna de las visitas médicas establecidas.

Informe a su médico de algún síntoma nuevo o que empeora, como: cambios del humor o del comportamiento, ansiedad, depresión, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o físicamente), o piensa en suicidarse o hacerse daño.

No deje de toma gabapentin para convulsiones sin antes hablar con su médico, aunque se sienta bien. Usted puede tener un aumento en convulsiones si deja de tomar gabapentin de forma repentina. Usted necesitará reducir su dosis lentamente antes de dejar de tomar la medicina por completo.

Comuníquese con su médico si sus convulsiones empeoran o las tiene con más frecuencia mientras está tomando gabapentin.

Lleve con usted una tarjeta de identificación que indique que usted está tomando gabapentin. Cualquier médico, dentista, o profesional del cuidado de la salud que lo trate debería saber que usted toma medicamentos para las convulsiones.

¿Qué es gabapentin?

Gabapentin es una medicina antiepiléptica, también conocida como anticonvulsante. Ésta afecta a los químicos y nervios del cuerpo que están involucrados en las causas de convulsiones y algunos tipos de dolores.

Gabapentin se usa solo o en combinación con otras medicinas para el tratamiento de las convulsiones que causan epilepsia en adultos y niños que tienen por lo menos 12 años de edad. Gabapentin también se usa con otras medicinas para el tratamiento de convulsiones parciales en niños que tienen de 3 a 12 años de edad.

Gabapentin también se usa en los adultos para el tratamiento del dolor de los nervios que causa el virus herpes o culebrilla (herpes zoster), y para el tratamiento del síndrome de la piernas inquietas (RLS, por sus siglas en Inglés).

Gabapentin puede también usarse para fines no mencionados en esta guía del medicamento.

¿Qué debería discutir con el profesional del cuidado de la salud antes de usar gabapentin?

Usted no debe usar este medicamento si es alérgico a gabapentin.

Para asegurarse que usted puede tomar gabapentin de forma segura, dígale a su médico si usted tiene cualquiera de estas otras condiciones:

enfermedad del riñón; enfermedad del hígado;

enfermedad del corazón; o

(para pacientes con síndrome de la piernas inquietas) si usted duerme durante el día o hace el turno de noche.

Usted puede tener pensamientos de suicidio mientras esté tomando esta medicina. Dígale a su médico si usted tiene depresión nuevo o que empeora o pensamientos de suicidio durante los primeros varios meses de tratamiento, o cuando cambie su dosis.

Su familia o quien lo cuide debe mantenerse alertas a cambios en su humor o síntomas. Su médico necesitará chequearlo con regularidad. No falte a ninguna de las visitas establecidas por su médico.

Categoría C del embarazo por la FDA. No se conoce si gabapentin causará daño al bebé nonato. Dígale a su médico si usted está embarazada o planea quedar embarazada mientras está usando este medicamento.

Gabapentin puede pasar a la leche materna y le puede hacer daño al bebé que está mamando. No use esta medicina sin antes hablar con su médico si le está dando de amamantar al bebé.

¿Cómo debo tomar gabapentin?

Tómelo exactamente como lo haya recetado su médico. No lo tome en cantidades mayores o menores, o por más tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripción.

La marca de Horizant de gabapentin no debe ser tomada durante el día. Para mejores resultados, tome Horizant con comida en aproximadamente a las 5 de la tarde.

La marca de Neurontin de gabapentin puede tomarse con o sin comida.

Si rompe la tableta y toma una mitad, tome la otra mitad en su próxima dosis. Cualquier tableta que se rompa debe usarse lo más pronto posible o dentro de pocos días.

Mida la medicina líquida con una cuchara o taza especial para medir la medicina, y no con una cuchara regular de mesa. Si no tiene con que medir su dosis, pídale una a su farmacéutico.

No deje de toma gabapentin para convulsiones sin primero hablar con su médico, aunque se sienta bien. Usted puede tener un aumento de convulsiones si deja de usar gabapentin de forma súbita. Usted tal vez necesite reducir su dosis lentamente antes de dejar de tomar el medicamento por completo.

Comuníquese con su médico si sus convulsiones empeoran o las tiene con más frecuencia mientras está tomando gabapentin.

Lleve con usted una tarjeta de identificación que indique que usted está tomando gabapentin. Cualquier médico, dentista, o profesional del cuidado de la salud que lo trate debería saber que usted toma medicamentos para las convulsiones.

Use gabapentin regularmente para obtener el mayor beneficio. Vuelva a llenar su prescripción antes de que se quede completamente sin medicina.

Este medicamento puede causar resultados inusuales con ciertas pruebas médicas. Dígale a cualquier médico que lo atiende que usted está usando gabapentin.

Guarde las tabletas y cápsulas de gabapentin a temperatura ambiente lejos de la luz y humedad.

Guarde la medicina líquida en el refrigerador. No la congele.

¿Qué sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sáltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome más medicina para alcanzar la dosis pasada.

¿Qué sucedería en una sobredosis?

Busque atención médica de emergencia o llame a la línea de Poison Help al 1 800 222 1222.

Los síntomas de sobredosis puede incluir visión borrosa, somnolencia, debilidad, arrastre de las palabras al hablar, o diarrea.

¿Qué debo evitar mientras tomo gabapentin?

Este medicamento puede causar visión borrosa o perjudicar su pensamiento o reacciones. Tenga cuidado al manejar o hacer otras actividades que demanden esté alerta y sea capaz de ver claramente.

Evite tomar un antiácido dentro de 2 horas antes o después de tomar gabapentin. Los antiácidos puede hacer difícil para que su cuerpo pueda absorber gabapentin.

¿Cuáles son los efectos secundarios posibles de gabapentin?

Busque atención médica de emergencia si usted tiene alguno de estos síntomas de una reacción alérgica: ronchas; fiebre, glándulas inflamadas; úlceras dolorosas en o alrededor de sus ojos o boca; dificultad para respirar; hinchazón de su cara, labios, lengua, o garganta.

Informe a su médico de algún síntoma nuevo o que empeora, como: cambios del humor o del comportamiento, ansiedad, depresión, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o físicamente), o piensa en suicidarse o hacerse daño.

Llame a su médico de inmediato si usted tiene un efecto secundario grave como:

aumento en convulsiones; fiebre, glándulas hinchadas, dolor de cuerpo, síntomas de la gripe;

sarpullido, moretones o sangrado fácil, hormigueo severo, entumecimiento, dolor, debilidad muscular;

dolor en la parte superior del estómago, pérdida del apetito, orina oscura, ictericia (color amarillo de la piel u ojos);

dolor de pecho, ritmo cardíaco irregular, sensación de que le falta aire al respirar;

confusión, náusea y vómito, hinchazón, ganancia de peso rápida, orinar menos de lo usual o nada en absoluto;

tos nueva o que empeora, fiebre, dificultad para respirar; o

movimiento de los ojos rápidos, hacia adelante y atrás.

Algunos de los efectos secundarios son más probables en los niños que toman gabapentin. Comuníquese con su médico si el niño que está tomando esta medicina tiene alguno de los efectos secundarios a seguir:

cambios en comportamiento; problemas de la memoria;

dificultad para concentrarse; o

inquieto, hostil, o agresivo.

Efectos secundarios de menor gravedad pueden incluir:

mareo, somnolencia, debilidad, sentirse cansado; náusea, diarrea, estreñimiento;

visión borrosa;

dolor de cabeza;

hinchazón en las mamas;

boca seca; o

pérdida del equilibrio o la coordinación.

Esta lista no menciona todos los efectos secundarios y puede ser que ocurran otros. Llame a su médico para consejos médicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

¿Qué otras drogas afectarán a gabapentin?

Dígale a su médico acerca de todas las medicinas que usted use, especialmente:

hydrocodone (Lortab, Vicodin, Vicoprofen, y otras); morphine (Kadian, MS Contin, Oramorph, y otras); o

naproxen (Naprosyn, Aleve, Anaprox, y otras).

Esta lista no incluye todas las drogas y pueden existir otras que tengan interacciones con gabapentin. Dígale a su médico acerca de todos los medicamentos que usted use. Incluya los productos que se obtienen con o sin receta, vitaminas, y productos herbarios. No empiece a usar un medicamento nuevo sin primero decirle a su médico.

¿Dónde puedo obtener más información?

Su farmacéutico le puede dar más información acerca de gabapentin.

Drug

Phenytekphenytoin

Entire Monograph

Adult Dosing

Dosage forms:  200,300 ER

Special Note

[formulation clarification]Info: phenytoin ER caps contain 8% less drug than chewable tabs and susp; monitor closely and consider dose adjustment if switching between products

seizure disorder

[300-400 mg PO div bid-tid]Max: 400 mg/dose; Info: may consider load of 15-20 mg/kg PO div in 3 doses 2-4h apart; adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs; if stable on bid-tid dosing, then may switch to qd dosing; do not open/crush/chew

renal dosing

[no adjustment]renal impairment: do not give oral loading regimen; HD/PD: no supplement

hepatic dosing

[adjust dose amount]hepatic impairment: do not give oral loading regimen

Peds Dosing

Dosage forms:  200,300 ER

Special Note

[formulation clarification]Info: phenytoin ER caps contain 8% less drug than chewable tabs and susp; monitor closely and consider dose adjustment if switching between products

seizure disorder

[7-10 yo]Dose: 7-8 mg/kg/day PO div bid-tid; Start: 5 mg/kg/day PO div bid-tid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs; if stable on bid-tid dosing, then may switch to qd dosing; do not open/crush/chew

[10-16 yo]Dose: 6-7 mg/kg/day PO div bid-tid; Start: 5 mg/kg/day PO div bid-tid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs; if stable on bid-tid dosing, then may switch to qd dosing; do not open/crush/chew

[>16 yo]see Adult Dosing

renal dosing

[no adjustment]

hepatic dosing

[adjust dose amount]hepatic impairment: decr. dose, amount not defined

Contraindications/Cautions

hypersens. to drug/class/compon. SA block (IM or IV use)

2nd or 3rd degree AV block (IM or IV use)

sinus bradycardia (IM or IV use)

Adams-Stokes syndrome (IM or IV use)

caution if hypotension (IM or IV use)

caution if cardiovascular dz (IM or IV use)

caution if renal impairment

caution if hepatic impairment

caution if diabetes mellitus

caution if pregnancy

caution in elderly pts

caution if porphyria

caution if alcohol use

caution if thyroid dz

avoid abrupt withdrawal

caution if HLA-B*1502-positive

caution if depression or hx

Drug Interactions

Contraindicated

boceprevircontraindicated: combo may decr. boceprevir levels, efficacy (hepatic metab. induced)

delavirdinecontraindicated: combo may decr. delavirdine levels, efficacy (hepatic metab. induced)

emtricitabine/rilpivirine/tenofovir disoproxilcontraindicated: combo may decr. rilpivirine levels, efficacy (hepatic metab. induced)

etravirinecontraindicated: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

lopinavir/ritonavircontraindicated w/ once daily lopinavir/ritonavir; use alternative or weigh risk/benefit w/ other regimens; monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

lurasidonecontraindicated: combo may decr. lurasidone levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

praziquantelcontraindicated; D/C phenytoin 4wk prior to praziquantel course, may restart phenytoin 1 day after last dose praziquantel: combo may decr. praziquantel levels, efficacy (hepatic metab. induced)

ranolazinecontraindicated: combo may decr. ranolazine levels, efficacy (hepatic metab. induced)

rilpivirinecontraindicated: combo may decr. rilpivirine levels, efficacy (hepatic metab. induced)

Avoid/Use Alternative

acetaminophen/codeineuse alternative or limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy; incr. risk of CNS and respiratory depression, psychomotor impairment (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

axitinibavoid combo: combo may decr. axitinib levels, efficacy (hepatic metab. induced)

bortezomibavoid combo: combo may decr. bortezomib levels, efficacy (hepatic metab. induced)

bosutinibavoid combo: combo may decr. bosutinib levels, efficacy (hepatic metab. induced)

cabazitaxelavoid combo: combo may decr. cabazitaxel levels, efficacy (hepatic metab. induced)

calcium channel blockers, dihydropyridinesuse alternative or monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)[calcium channel blockers, dihydropyridines: amlodipine, amlodipine/benazepril, felodipine, isradipine, nicardipine, nifedipine, nimodipine, nisoldipine]

calcium channel blockers, othersuse alternative or monitor for efficacy: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)[calcium channel blockers, others: diltiazem, trandolapril/verapamil, verapamil]

cobicistatavoid combo: combo may decr. cobicistat levels, efficacy (hepatic metab. induced)[cobicistat: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil]

contraceptives, oral combocaution advised; use additional non-hormonal or alternative contraception: combo may result in loss of seizure control; combo may decr. hormonal contraceptive levels, efficacy (estrogen-induced fluid retention; hepatic metab. induced)[contraceptives, oral combo: desogestrel/ethinyl estradiol, drospirenone/ethinyl estradiol, drospirenone/ethinyl estradiol/levomefolate, estradiol valerate/dienogest, ethynodiol/ethinyl estradiol, levonorgestrel/ethinyl estradiol, norethindrone/ethinyl estradiol, norethindrone/mestranol, norgestimate/ethinyl estradiol, norgestrel/ethinyl estradiol]

contraceptives, oral progestinuse additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)[contraceptives, oral progestin: norethindrone]

contraceptives, other combocaution advised; use additional non-hormonal or alternative contraception: combo may result in loss of seizure control; combo may decr. hormonal contraceptive levels, efficacy (estrogen-induced fluid retention; hepatic metab. induced)[contraceptives, other combo: etonogestrel/ethinyl estradiol vaginal, norelgestromin/ethinyl estradiol transdermal]

crizotinibavoid combo or use alternative: combo may decr. crizotinib levels, efficacy (hepatic metab. induced)

deferasiroxavoid combo or consider incr. initial deferasirox dose to 30 mg/kg/day, monitor ferritin and phenytoin levels: combo may decr. deferasirox efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; hepatic metab. inhibited)

dopamineuse alternative or monitor BP: combo w/ IV phenytoins may incr. risk of severe hypotension (mechanism unknown, possible additive effects)

dronedaroneavoid combo: combo may decr. dronedarone levels, efficacy (hepatic metab. induced)

elvitegraviravoid combo or use alternative: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)[elvitegravir: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil]

enzalutamideavoid combo: combo may decr. levels of both drugs, efficacy (hepatic metab. induced)

erlotinibuse alternative or consider incr. erlotinib dose >150 mg/day: combo may decr. erlotinib levels (hepatic metab. induced)

etonogestrel subdermal implantuse additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)

everolimusavoid combo or adjust dose based on indication; incr. everolimus dose up to 20 mg/day in breast CA, PNET, renal cell CA, or renal angiomyolipoma w/ TSC pts; double everolimus dose and monitor levels in SEGA pts; monitor levels in transplant pts: combo may decr. everolimus levels, efficacy (hepatic metab. induced)

ginkgo bilobaavoid consumption of raw ginkgo seeds: combo may decr. anticonvulsant efficacy (antagonistic effects, high dose ginkgotoxin may cause seizures)[ginkgo biloba: Eun-haeng, fossil tree, ginkgo (Ginkgo biloba), Ginkgo biloba, ginkyo, icho, ityo, Japanese silver apricot, kew tree, maidenhair tree, salisburia, silver apricot]

hydrocodone/acetaminophenuse alternative or limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy; incr. risk of CNS and respiratory depression, psychomotor impairment (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

irinotecanavoid combo or use alternative; consider switch to non-enzyme inducing anticonvulsant >2wk prior to irinotecan start: combo may decr. irinotecan and active metabolite levels, efficacy (hepatic metab. induced)

ivacaftoravoid combo: combo may decr. ivacaftor levels, efficacy (hepatic metab. induced)

ixabepiloneuse alternative: combo may decr. ixabepilone levels, efficacy (hepatic metab. induced)

lapatinibavoid combo or consider incr. lapatinib dose gradually up to 4500 mg/day; monitor phenytoin levels: combo may decr. lapatinib levels, efficacy; may incr. phenytoin levels, risk of adverse effects, toxicity (hepatic metab. induced; hepatic metab. inhibited)

levonorgestreluse alternative non-hormonal contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)

linagliptinuse alternative: combo may decr. linagliptin levels, efficacy (hepatic metab. induced, p-glycoprotein induced, antagonistic effects)

linagliptin/metforminuse alternative: combo may decr. linagliptin levels, efficacy (hepatic metab. induced, P-glycoprotein induced)

local anestheticsavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)[local anesthetics: bupivacaine, bupivacaine liposomal, chloroprocaine, lidocaine, mepivacaine, procaine, ropivacaine]

local anesthetics/epinephrineavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)[local anesthetics/epinephrine: articaine/epinephrine]

medroxyprogesterone acetateuse additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)

methotrexateuse alternative or monitor efficacy, toxicity, levels: combo may incr. methotrexate toxicity and decr. efficacy; may decr. phenytoin levels, efficacy (mechanism unknown; absorption decreased)

mifepristoneavoid combo if daily mifepristone use; caution advised if pregnancy termination use: combo may decr. mifepristone levels, efficacy (hepatic metab. induced)

milk thistleavoid combo or monitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects (hepatic metab. inhibited)[milk thistle: Carduus marianum, holy thistle, Lady's thistle, legalon, Marian thistle,

Mary thistle, milk thistle (Silybum marianum), silibinin, silybin, Silybum marianum, silymarin, St. Mary thistle]

nilotinibavoid combo or consider incr. nilotinib dose and monitor ECG, phenytoin levels: combo may incr. phenytoin levels, risk of toxicity; may decr. phenytoin or nilotinib levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

oxycodone/acetaminophenuse alternative or limit acetaminophen <2 g/day: combo may decr. oxycodone levels, efficacy; incr. risk of acetaminophen toxicity, decr. efficacy; incr. risk of CNS and respiratory depression, psychomotor impairment (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

pazopanibcontraindicated if chronic use of strong CYP3A4 inducer, otherwise avoid combo or use alternative: combo may decr. pazopanib levels, efficacy (hepatic metab. induced)

pentazocine/acetaminophenuse alternative or limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy; incr. risk of CNS and respiratory depression, psychomotor impairment (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

posaconazoleweigh risk/benefit, monitor phenytoin levels: combo may decr. posaconazole levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. altered)

rivaroxabanavoid combo: combo may decr. rivaroxaban levels, efficacy (hepatic metab. induced, P-glycoprotein induced)

roflumilastavoid combo: combo may decr. roflumilast levels, efficacy (hepatic metab. induced)

sunitinibuse alternative or consider incr. sunitinib dose to max 87.5 mg/day in GIST or RCC pts and max 62.5 mg/day in PNET pts: combo may decr. sunitinib levels, efficacy (hepatic metab. induced)

tadalafilavoid combo in pulmonary HTN pts; caution advised for ED pts: combo may decr. tadalafil levels, efficacy (hepatic metab. induced)

telapreviravoid combo or monitor phenytoin levels and titrate dose: combo may alter phenytoin levels, decr. efficacy or incr. toxicity; may decr. telaprevir levels, efficacy (hepatic metab. altered; hepatic metab. induced, p-glycoprotein induced)

temsirolimusavoid combo or consider incr. temsirolimus dose to 50 mg/wk: combo may decr. temsirolimus and sirolimus levels, efficacy (hepatic metab. induced)

ticagreloravoid combo: combo may decr. ticagrelor levels, efficacy (hepatic metab. induced)

tolvaptanavoid combo or consider incr. tolvaptan dose: combo may decr. tolvaptan levels, efficacy (hepatic metab. induced)

tramadolavoid combo: combo may decr. tramadol levels, efficacy; may incr. risk of CNS depression, psychomotor impairment, alter seizure control (hepatic metab. induced; additive effects, decr. seizure threshold)

tramadol/acetaminophenuse alternative: combo may incr. risk of acetaminophen toxicity, decr. tramadol levels and efficacy; incr. risk of CNS depression, psychomotor impairment; tramadol may decr. seizure threshold (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

ulipristaluse alternative non-hormonal contraception: combo may decr. ulipristal levels, contraceptive efficacy (hepatic metab. induced)

vandetanibavoid combo: combo may decr. vandetanib levels, efficacy (hepatic metab. induced)

Monitor/Modify Tx

acarbosemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

acetaminophen/aspirincaution advised, especially w/ high dose aspirin or salicylates, monitor phenytoin levels; limit acetaminophen <2 g/day: combo w/ aspirin may incr. phenytoin levels, risk of toxicity; combo may incr. risk of acetaminophen toxicity, decr. efficacy (protein binding displacement; hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/aspirin/caffeinecaution advised, especially w/ high dose aspirin or salicylates, monitor phenytoin levels; limit acetaminophen <2 g/day: combo w/ aspirin may incr. phenytoin levels, risk of toxicity; combo may decr. caffeine levels, efficacy; combo may incr. risk of acetaminophen toxicity, decr. efficacy (protein binding displacement; hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/caffeinecaution advised; limit acetaminophen <2 g/day: combo may decr. caffeine levels,

efficacy; combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/caffeine/CNS depressant comboscaution advised, limit acetaminophen <2 g/day: combo may decr. caffeine levels, efficacy; may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic acetaminophen metabolite formation)[acetaminophen/caffeine/CNS depressant combos: acetaminophen/caffeine/dihydrocodeine, butalbital/acetaminophen/caffeine, butalbital/acetaminophen/caffeine/codeine]

acetaminophen/chlorpheniraminecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/chlorpheniramine/dextromethorphancaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/chlorpheniramine/dextromethorphan/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/chlorpheniramine/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/dextromethorphancaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/dextromethorphan/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophen/dextromethorphan/phenylephrine: acetaminophen/dextromethorphan/phenylephrine, acetaminophen/dextromethorphan/phenylephrine/guaifenesin]

acetaminophen/dextromethorphan/pseudoephedrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophen/dextromethorphan/pseudoephedrine: acetaminophen/dextromethorphan/pseudoephedrine/guaifenesin]

acetaminophen/diphenhydraminecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/diphenhydramine/dextromethorphancaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/diphenhydramine/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/doxylamine/dextromethorphancaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/doxylamine/dextromethorphan/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/doxylamine/dextromethorphan/pseudoephedrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/doxylamine/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/magnesium salicylate/pamabromcaution advised, especially w/ high dose aspirin or salicylates, monitor phenytoin levels; limit acetaminophen <2 g/day: combo w/ salicylates may incr. phenytoin levels, risk of toxicity; combo may incr. risk of acetaminophen toxicity, decr. efficacy (protein binding displacement; hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/pamabromcaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced, incr. toxic metabolite formation)

acetaminophen/pheniramine/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophen/phenylephrine: acetaminophen/phenylephrine, acetaminophen/phenylephrine/guaifenesin]

acetaminophen/pseudoephedrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophen/pseudoephedrine: acetaminophen/pseudoephedrine/guaifenesin]

acetaminophenscaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophens: acetaminophen, acetaminophen rectal, acetaminophen/guaifenesin, isometheptene/dichloralphenazone/acetaminophen]

acyclovirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown)

aliskiren/amlodipinemonitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)

aliskiren/amlodipine/hydrochlorothiazidemonitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)

amiodaronemonitor levels, efficacy: combo may incr. phenytoin levels, risk of toxicity; decr. amiodarone levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

amlodipine/ARB combosmonitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)[amlodipine/ARB combos: amlodipine/olmesartan, amlodipine/valsartan, telmisartan/amlodipine]

amlodipine/ARB/thiazide combosmonitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)[amlodipine/ARB/thiazide combos: amlodipine/valsartan/hydrochlorothiazide, olmesartan/amlodipine/hydrochlorothiazide]

amlodipine/atorvastatinmonitor BP, cholesterol levels: combo may decr. both statin and calcium channel blocker levels, efficacy (hepatic metab. induced)

antacidsgive oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)[antacids: aluminum hydroxide, aluminum hydroxide/magnesium carbonate, aluminum hydroxide/magnesium hydroxide, aluminum hydroxide/magnesium hydroxide/simethicone, aluminum hydroxide/magnesium trisilicate, magnesium hydroxide]

aprepitantcaution advised, monitor efficacy: combo may decr. levels, efficacy of both drugs

(hepatic metab. induced)[aprepitant: aprepitant, fosaprepitant]

aripiprazoleadjust aripiprazole dose, may be doubled up to max 30 mg/day: combo may decr. aripiprazole levels, efficacy (hepatic metab. induced)

aspirincaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/caffeinecaution advised, especially w/ high dose aspirin or salicylates, monitor phenytoin levels: combo w/ aspirin may incr. phenytoin levels, risk of toxicity; combo may decr. caffeine levels, efficacy (protein binding displacement; hepatic metab. induced)

aspirin/calcium carbonategive oral phenytoin 2h before or 4h after oral calcium salts; caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo w/ calcium may decr. phenytoin levels, efficacy; combo w/ aspirin may incr. phenytoin levels, risk of toxicity (absorption decreased; protein binding displacement)

aspirin/chlorpheniramine/dextromethorphancaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/chlorpheniramine/dextromethorphan/phenylephrinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/chlorpheniramine/phenylephrinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/diphenhydraminecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/dipyridamolecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/doxylamine/dextromethorphan/phenylephrinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/phenylephrinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

atazanavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

bexarotenecaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

bismuth subcitrate potassium/metronidazole/tetracyclinemonitor levels: combo w/ metronidazole may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

bismuth subsalicylate/metronidazole/tetracyclinemonitor levels: combo w/ metronidazole, salicylates may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited, protein binding displacement)

bosentancaution advised, monitor phenytoin levels: combo may decr. bosentan levels, decr. phenytoin levels (hepatic metab. induced)

butalbital/acetaminophencaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced, incr. toxic acetaminophen metabolite formation)

calcitriolmonitor efficacy; consider calcitriol dose adjustment: enzyme induction may decr. endogenous calcitriol levels, resulting in incr. supplemental calcitriol requirements (hepatic metab. induced)

calcium carbonate/magnesium hydroxidegive oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)[calcium carbonate/magnesium hydroxide: calcium carbonate/magnesium hydroxide, calcium carbonate/magnesium hydroxide/simethicone]

calcium saltsgive phenytoin 2h before or 4h after oral calcium salts: combo may decr. phenytoin levels, efficacy (absorption decreased)[calcium salts: calcium acetate, calcium carbonate, calcium carbonate/simethicone, calcium chloride, calcium citrate, calcium gluconate, risedronate/calcium carbonate]

capecitabinemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown)

carbamazepinemonitor levels: combo may alter levels of both drugs; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

carisoprodol/aspirincaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

carisoprodol/aspirin/codeinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. risk of CNS depression, psychomotor impairment; combo may incr. phenytoin levels, risk of toxicity (additive effects; protein binding displacement)

carvedilolmonitor efficacy: combo may decr. carvedilol levels, efficacy (hepatic metab. induced)

caspofunginconsider incr. caspofungin dose to 70 mg/day in adults, 70 mg/m^2 in peds: combo may decr. caspofungin levels, efficacy (hepatic metab. induced)

chloramphenicolmonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

cimetidinemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

cinacalcetmonitor iPTH, serum calcium: combo may decr. cinacalcet levels, efficacy (hepatic metab. induced)

ciprofloxacinmonitor levels: combo may incr. or decr. phenytoin levels (hepatic metab. altered)

clarithromycinmonitor phenytoin levels: combo may decr. clarithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown)

clopidogrelcaution advised, monitor phenytoin levels: may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

clozapinecaution advised, monitor for altered response to clozapine: combo may decr. clozapine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

CNS depressant/aspirin/caffeine comboscaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may decr. caffeine levels, efficacy; combo may incr. phenytoin levels, risk of toxicity (hepatic metab. induced; phenytoin protein binding displacement)

[CNS depressant/aspirin/caffeine combos: butalbital/aspirin/caffeine, butalbital/aspirin/caffeine/codeine, dihydrocodeine/aspirin/caffeine]

colesevelamgive phenytoin >4h before; monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (absorption decreased)

cyclosporinemonitor levels: combo may decr. cyclosporine levels, efficacy (hepatic metab. induced)[cyclosporine: cyclosporine modified, cyclosporine non-modified]

darunavirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

diazepamcaution advised, monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity; may incr. risk of CNS depression, psychomotor impairment (mechanism unknown; additive effects)[diazepam: diazepam, diazepam rectal]

digoxinmonitor digoxin levels: combo may decr. digoxin levels, efficacy (P-glycoprotein induced)

disopyramidemonitor levels: combo may decr. disopyramide levels, efficacy (hepatic metab. induced)

disulfirammonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

doxorubicinsmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown)[doxorubicins: doxorubicin, doxorubicin liposomal]

efavirenzcaution advised, monitor phenytoin levels: combo may decr. efavirenz levels, efficacy; alter phenytoin levels (hepatic metab. altered)

efavirenz/emtricitabine/tenofovir disoproxilcaution advised, monitor phenytoin levels: combo w/ efavirenz may alter phenytoin levels; decr. efavirenz levels, efficacy (hepatic metab. altered)

erythromycinsmonitor phenytoin levels: combo may decr. erythromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown)

[erythromycins: erythromycin base, erythromycin ethylsuccinate, erythromycin lactobionate, erythromycin stearate, erythromycin/sulfisoxazole]

ethosuximidemonitor ethosuximide levels: combo may decr. ethosuximide levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; mechanism unknown)

exemestaneadjust exemestane dose to 50 mg/day: combo may decr. exemestane levels, efficacy (hepatic metab. induced)

exenatidemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

ezogabineconsider incr. ezogabine dose; caution advised: combo may decr. ezogabine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

famotidine/calcium carbonate/magnesium hydroxidegive phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)

felbamatemonitor phenytoin levels, consider phenytoin dose reduction: combo may incr. phenytoin levels, risk of toxicity; decr. felbamate levels, efficacy (hepatic metab. altered)

fenofibratemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)[fenofibrate: fenofibrate, fenofibrate micronized, fenofibric acid]

fluconazolemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fluorouracilmonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fluoxetinemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fluvastatinmonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fluvoxaminemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fosamprenavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

gefitinibconsider incr. gefitinib dose to 500 mg/day: combo may decr. gefitinib levels, efficacy (hepatic metab. induced)

gemfibrozilmonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

growth hormonemonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)[growth hormone: somatropin (recombinant)]

guanfacineconsider incr. guanfacine dose: combo may decr. guanfacine levels, efficacy (hepatic metab. induced)

imatinibincr. imatinib dose 50%, monitor response: combo may decr. imatinib levels, efficacy (hepatic metab. induced)

indinavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

influenza vaccinecaution advised, monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown, hepatic metab. possibly inhibited)[influenza vaccine: influenza intradermal vaccine, influenza vaccine]

insulinsmonitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects)[insulins: insulin aspart, insulin aspart protamine/insulin aspart, insulin detemir, insulin glargine, insulin glulisine, insulin lispro, insulin lispro protamine/insulin lispro, insulin NPH, insulin NPH/regular, insulin regular]

isoniazidmonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

itraconazolecaution advised, monitor efficacy: combo may decr. antifungal levels, efficacy (hepatic metab. induced)

ketoconazolecaution advised, monitor phenytoin levels: combo may decr. antifungal levels, efficacy; incr. phenytoin levels, risk of toxicity (hepatic metab. altered)

lamotriginecaution advised, adjust lamotrigine initial dose escalation; adjust maint. dose if hydantoin added or stopped: combo may decr. lamotrigine levels by 40% (hepatic metab. induced)

lansoprazole/amoxicillin/clarithromycinmonitor phenytoin levels: combo may decr. clarithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown)

leflunomidemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

leucovorincaution advised, monitor levels: combo may decr. anticonvulsant levels, efficacy (mechanism unknown)

levoleucovorincaution advised, monitor levels: combo may decr. anticonvulsant levels, efficacy (mechanism unknown)

liraglutidemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

lithiummonitor levels: combo may incr. lithium levels, risk of toxicity (mechanism unknown)

magnesium hydroxide/mineral oilgive oral phenytoin 2h before or 4h after: combo w/ antacids may decr. phenytoin levels, efficacy (absorption decreased)

magnesium saltsgive oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)[magnesium salts: magnesium citrate, magnesium gluconate, magnesium oxide, magnesium sulfate]

maravirocadjust maraviroc dose to 600 mg bid, unless combined w/ hepatic metab. inhibitor requiring decr. maraviroc dose of 150 mg bid: combo may decr. maraviroc levels, efficacy (hepatic metab. induced)

mefloquinemonitor levels, efficacy: combo may decr. levels, efficacy of both drugs (mechanism unknown, hepatic metab. possibly altered)

metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

metformin/sulfonylurea combosmonitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects)[metformin/sulfonylurea combos: glipizide/metformin, glyburide/metformin]

methadonemonitor for efficacy, withdrawal: combo may decr. methadone levels, efficacy; precipitate opioid withdrawal symptoms (hepatic metab. induced)

methylphenidatemonitor levels: combo may incr. phenytoin levels, risk of toxicity; methylphenidate may lower seizure threshold (mechanism unknown, hepatic metab. possibly inhibited)[methylphenidate: dexmethylphenidate, methylphenidate, methylphenidate transdermal]

metronidazolemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

miglitolmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

modafinilmonitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects; may decr. armodafinil or modafinil levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)[modafinil: armodafinil, modafinil]

nateglinidemonitor glucose: combo may decr. nateglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

nelfinavirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

nitazoxanidemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

olanzapine/fluoxetinemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

omeprazolemonitor levels, esp. if omeprazole dose >20 mg/day: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)[omeprazole: omeprazole, omeprazole/sodium bicarbonate]

omeprazole/clarithromycin/amoxicillinmonitor phenytoin levels: combo w/ clarithromycin, omeprazole may incr phenytoin levels, risk of toxicity; combo may decr. clarithromycin levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

oxcarbazepinemonitor levels: combo may incr. phenytoin levels, risk of toxicity; decr. oxcarbazepine levels; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. altered; additive effects)

oxycodone/aspirincaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may decr. oxycodone levels, efficacy; incr. risk of CNS depression, psychomotor impairment; combo may incr. phenytoin levels, risk of toxicity (hepatic metab. induced; additive effects; protein binding displacement)

paroxetinemonitor phenytoin levels, monitor paroxetine efficacy: combo may incr. phenytoin levels, risk of toxicity; may decr. paroxetine levels, efficacy (hepatic metab. altered)

phenobarbitalmonitor levels: combo may decr. levels of both drugs (hepatic metab. induced)

phenobarbital/hyoscyamine/atropine/scopolaminemonitor levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

pioglitazonemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

pioglitazone/glimepiridemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

pioglitazone/metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

primidonemonitor levels: combo may incr. phenobarbital levels, decr. phenytoin levels (hepatic metab. induced; incr. conversion of primidone to phenobarbital)

propoxyphene/acetaminophencaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy; decr. propoxyphene levels, efficacy, incr. active metabolite formation, risk of toxicity; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced, incr. formation of toxic acetaminophen and propoxyphene metabolites; additive effects)[propoxyphene/acetaminophen: propoxyphene hydrochloride/acetaminophen, propoxyphene napsylate/acetaminophen]

quinidinemonitor levels: combo may decr. quinidine levels, efficacy (hepatic metab. induced)[quinidine: quinidine gluconate, quinidine sulfate]

repaglinidemonitor glucose: combo may decr. repaglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

repaglinide/metforminmonitor glucose: combo may decr. repaglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

rifampinsmonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)[rifampins: rifampin, rifampin/isoniazid, rifampin/isoniazid/pyrazinamide]

rifapentinemonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

ritonavirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

rosiglitazonemonitor glucose: combo may decr. rosiglitazone levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

rosiglitazone/glimepiridemonitor glucose: combo may decr. rosiglitazone levels; may decr. hypoglycemic agent efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

rosiglitazone/metforminmonitor glucose: combo may decr. rosiglitazone levels; may decr. hypoglycemic agent

efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

rufinamidemonitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects; decr. rufinamide levels, efficacy; incr. risk of CNS depression, psychomotor impairment (mechanism unknown; hepatic metab. induced; additive effects)

salicylates, non-acetylatedcaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)[salicylates, non-acetylated: bismuth subsalicylate, choline magnesium trisalicylate, magnesium salicylate, salsalate]

saquinavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

saxagliptinmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

saxagliptin/metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

sertralinemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown, hepatic metab. possibly inhibited)

sevelamergive anticonvulsant 1h before or 3h after, monitor efficacy: combo may decr. anticonvulsant levels, efficacy (absorption possibly decreased)

sitagliptinmonitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects)

sitagliptin/metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

sitagliptin/simvastatinmonitor statin efficacy; monitor glucose: combo may decr. statin levels, efficacy; may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (hepatic metab. induced; antagonistic effects)

statins, CYP3A4 substratesmonitor efficacy: combo may decr. statin levels, efficacy (hepatic metab. induced)[statins, CYP3A4 substrates: atorvastatin, ezetimibe/simvastatin, lovastatin, simvastatin]

sucralfategive oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)

sulfonylureasmonitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (hepatic metab. induced; antagonistic effects)[sulfonylureas: chlorpropamide, glimepiride, glipizide, glyburide, glyburide micronized, tolazamide, tolbutamide]

tacrolimusmonitor levels: combo may decr. tacrolimus levels, efficacy (hepatic metab. induced)

telithromycinmonitor phenytoin levels: combo may decr. telithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown)

tesamorelinmonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

theophyllinesmonitor levels: combo may decr. theophylline levels, efficacy (hepatic metab. induced)[theophyllines: aminophylline, theophylline]

thyroid hormonesmonitor thyroid function, adjust thyroid replacement dose if needed: combo may decr. thyroid hormone efficacy (hepatic metab. induced, clearance increased)[thyroid hormones: levothyroxine, liothyronine, liotrix, thyroid (porcine)]

tiagabinecaution advised; decr. tiagabine dose if other tx stopped or decreased: combo may incr. risk of CNS depression, psychomotor impairment; tiagabine dosing based on concomitant hepatic enzyme inducing drugs, levels may incr. >2x when induction removed (hepatic metab. induced, clearance incr. 60%; additive effects)

ticlopidinemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

tinidazolemonitor levels, efficacy: combo may incr. phenytoin levels, risk of toxicity; decr. tinidazole levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

tipranavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

TNF blocking agentsmonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. altered; TNF blockers may inhibit inflammatory cytokine-induced downregulation of CYP450 enzymes resulting in relative induction of enzymes upon tx start and downregulation upon D/C)[TNF blocking agents: adalimumab, certolizumab pegol, etanercept, golimumab, infliximab]

tocilizumabmonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. altered; tocilizumab may inhibit inflammatory cytokine-induced downregulation of CYP450 enzymes resulting in relative induction of enzymes upon tx start and downregulation upon D/C)

topiramatemonitor levels: combo may incr. phenytoin levels, risk of toxicity; decr. topiramate levels, efficacy (hepatic metab. altered)[topiramate: phentermine hydrochloride/topiramate, topiramate]

trazodonecaution advised, monitor phenytoin levels: combo may decr. trazodone levels, efficacy; may incr. phenytoin levels, risk of toxicity (hepatic metab. induced; mechanism unknown)

trimethoprimmonitor levels, CBC: combo may incr. phenytoin levels, risk of toxicity, risk of megaloblastic anemia (hepatic metab. inhibited, additive/synergistic folate antagonism)

trimethoprim/sulfamethoxazolemonitor levels, CBC: combo w/ trimethoprim may incr. phenytoin levels, risk of toxicity, risk of megaloblastic anemia (hepatic metab. inhibited, additive/synergistic folate antagonism)

ustekinumabmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. possibly altered; ustekinumab may normalize hepatic enzyme formation suppressed by incr. cytokine levels)

valacyclovirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown)

valproic acid derivativesmonitor levels; caution advised: combo may decr. valproic acid levels, efficacy; may incr. phenytoin levels, risk of toxicity; may incr. risk of CNS depression, psychomotor

impairment (hepatic metab. altered; additive effects)[valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid]

vigabatrinmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

voriconazoleincr. voriconazole dose per pkg insert; monitor phenytoin levels: combo may decr. antifungal levels, efficacy; incr. phenytoin levels, risk of toxicity (hepatic metab. induced; hepatic metab. inhibited)

warfarinmonitor INR: combo may decr. INR, warfarin efficacy and transiently incr. INR, risk of bleeding (hepatic metab. induced, protein binding displacement)

zafirlukastmonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

Caution Advised

abiraterone acetatecaution advised: combo may decr. abiraterone levels, efficacy (hepatic metab. induced)

aldesleukincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

alendronate/cholecalciferolcaution advised: combo may decr. cholecalciferol efficacy (hepatic metab. induced)

alfentanilcaution advised: combo may decr. alfentanil efficacy (hepatic metab. induced)

apomorphinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive/synergistic effects)

artemether/lumefantrinecaution advised: combo may decr. artemether/lumefantrine levels, efficacy (hepatic metab. induced)

azelastine nasalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal]

belataceptcaution advised: combo may decr. phenytoin levels, efficacy (hepatic metab. possibly

altered; belatacept may normalize hepatic enzyme formation suppressed by incr. cytokine levels)

benzocainecontraindicated if <1 yo, otherwise caution advised: combo w/ benzocaine may incr. risk of methemoglobinemia (additive effects)[benzocaine: benzalkonium chloride/benzocaine/zinc chloride oropharyngeal, benzethonium chloride/benzocaine topical, benzocaine oropharyngeal, benzocaine topical, benzocaine/allantoin/dimethicone/petrolatum topical, benzocaine/butamben/tetracaine topical, benzocaine/camphor/allantoin/dimethicone/petrolatum topical, benzocaine/camphor/allantoin/petrolatum topical, benzocaine/camphor/menthol/allantoin/dimethicone/petrolatum topical, benzocaine/glycerin oropharyngeal, benzocaine/menthol oropharyngeal, benzocaine/menthol topical, benzocaine/pectin oropharyngeal, benzocaine/petrolatum topical, benzocaine/zinc chloride oropharyngeal]

benzocaine/dextromethorphan comboscontraindicated if <1 yo, otherwise caution advised: combo w/ benzocaine may incr. risk of methemoglobinemia (additive effects)[benzocaine/dextromethorphan combos: benzocaine/dextromethorphan oropharyngeal, benzocaine/menthol/dextromethorphan oropharyngeal]

benzodiazepines, CYP3A4 substratescaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)[benzodiazepines, CYP3A4 substrates: alprazolam, midazolam, triazolam]

benzodiazepines, othercaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[benzodiazepines, other: clobazam, estazolam, lorazepam, oxazepam, temazepam]

black cohoshcaution advised: combo may incr. risk of hepatotoxicity (additive toxicity)[black cohosh: Actaea racemosa, baneberry, black cohosh (Actaea racemosa), black snakeroot, bugbane, bugwort, Cimicifuga racemosa, macrotys, rattle root, rattlesnake root, rattletop, rattleweed, squawroot]

bromocriptinecaution advised: combo may decr. bromocriptine levels, efficacy (hepatic metab. induced)

budesonidecaution advised: combo may decr. budesonide levels, efficacy (hepatic metab. induced)

buprenorphinecaution advised: combo may decr. buprenorphine levels, efficacy (hepatic metab.

induced)[buprenorphine: buprenorphine, buprenorphine transdermal, buprenorphine/naloxone]

bupropioncaution advised: combo may decr. buproprion efficacy (hepatic metab. induced)[bupropion: bupropion hydrobromide, bupropion hydrochloride]

buspironecaution advised: combo may decr. buspirone levels, efficacy (hepatic metab. induced)

busulfancaution advised: combo may decr. busulfan levels, efficacy (hepatic metab. induced)

caffeinecaution advised: combo may decr. caffeine levels, efficacy (hepatic metab. induced)[caffeine: caffeine, caffeine citrate, caffeine/sodium benzoate]

carbidopa/levodopacaution advised: combo may decr. levodopa efficacy (mechanism unknown)

carbidopa/levodopa/entacaponecaution advised: combo may decr. levodopa efficacy (mechanism unknown)

carbonic anhydrase inhibitors, systemiccaution advised: combo may incr. risk of osteomalacia (calcium renal excretion increased, metabolic acidosis)[carbonic anhydrase inhibitors, systemic: acetazolamide, methazolamide]

chlordiazepoxidecaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

clonazepamcaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

clorazepatecaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

colchicinecaution advised: combo may decr. colchicine levels, efficacy (hepatic metab. induced)

conivaptancaution advised: combo may decr. conivaptan levels, efficacy (hepatic metab. induced)

corticosteroids, systemiccaution advised: combo may decr. corticosteroid levels, efficacy (hepatic metab. induced)[corticosteroids, systemic: betamethasone sodium phosphate/betamethasone acetate, cortisone, dexamethasone, dexamethasone sodium phosphate, hydrocortisone,

hydrocortisone sodium succinate, methylprednisolone, methylprednisolone acetate, methylprednisolone sodium succinate, prednisolone, prednisone, triamcinolone acetonide]

cyclophosphamidecaution advised: combo may incr. cyclophosphamide active metabolite levels, risk of toxicity (hepatic metab. induced, incr. active metabolite formation)

dantrolenecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

dapsonecaution advised: combo may decr. dapsone levels, efficacy (hepatic metab. induced)

darifenacincaution advised: combo may decr. darifenacin levels, efficacy (hepatic metab. induced)

dasatinibcaution advised: combo may decr. dasatinib levels, efficacy (hepatic metab. induced)

diazoxidecaution advised: combo may incr. risk of hyperglycemia; combo w/ PO diazoxide may decr. phenytoin levels, incr. risk of seizures (additive effects; mechanism unknown)

diclofenaccaution advised: combo may decr. diclofenac levels, efficacy (hepatic metab. induced)[diclofenac: diclofenac potassium, diclofenac sodium, diclofenac/misoprostol]

docetaxelcaution advised: combo may decr. docetaxel levels, efficacy (hepatic metab. induced)

donepezilcaution advised: combo may decr. donepezil levels, efficacy (hepatic metab. induced)

doxercalciferolcaution advised: combo may decr. doxercalciferol efficacy (hepatic metab. induced)

doxycyclinecaution advised, monitor efficacy: combo may decr. doxycycline levels, efficacy (mechanism unknown)

eplerenonecaution advised: combo may decr. eplerenone levels, efficacy (hepatic metab. induced)

ergotamine/caffeinecaution advised: combo may decr. caffeine levels, efficacy (hepatic metab. induced)

eszopiclonecaution advised: combo may decr. eszopiclone levels, efficacy (hepatic metab. induced)

ethanolcaution advised: combo may incr. risk of CNS depression, alter phenytoin levels, incr. risk of seizures (additive effects, hepatic metab. induced w/ chronic and inhibited w/ acute alcohol use; alcohol withdrawal or excessive use may lower seizure threshold)

fentanylcaution advised: combo may decr. fentanyl levels, efficacy (hepatic metab. induced)[fentanyl: fentanyl, fentanyl nasal, fentanyl transdermal, fentanyl transmucosal]

flurazepamcaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

gabapentincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[gabapentin: gabapentin, gabapentin enacarbil]

green teacaution advised: combo may reduce effects of caffeine in green tea (hepatic metab. induced)[green tea: Camellia sinensis, Camellia thea, Chinese tea, green tea (Camellia sinensis), green tea extract, GTE, Japanese tea, Matsu-cha tea, Theaceae, theifers]

haloperidolcaution advised: combo may decr. haloperidol levels, efficacy (mechanism unknown)[haloperidol: haloperidol, haloperidol decanoate, haloperidol lactate]

HRT, estrogencaution advised: combo may result in loss of seizure control; combo may decr. estrogen levels, efficacy (estrogen-induced fluid retention; hepatic metab. induced)[HRT, estrogen: estradiol, estradiol acetate, estradiol cypionate, estradiol transdermal, estradiol vaginal, estradiol valerate, estrogens, conjugated, estrogens, conjugated (synthetic), estrogens, conjugated B (synthetic), estrogens, conjugated vaginal, estrogens, esterified, estrogens, esterified/methyltestosterone, estropipate]

HRT, estrogen/progestin combocaution advised: combo may result in loss of seizure control; combo may decr. estrogen, progestin levels, effica (estrogen-induced fluid retention; hepatic metab. induced)[HRT, estrogen/progestin combo: drospirenone/estradiol, estradiol/levonorgestrel transdermal, estradiol/norethindrone acetate, estradiol/norethindrone acetate transdermal, estradiol/norgestimate, estrogens, conjugated/medroxyprogesterone, norethindrone acetate/ethinyl estradiol]

HRT, progestincaution advised: combo may decr. progestin levels, efficacy (hepatic metab. induced)[HRT, progestin: medroxyprogesterone, norethindrone acetate]

hydromorphonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

hydroxyprogesterone (hormone replacement)caution advised: combo may decr. hydroxyprogesterone levels, efficacy (hepatic metab. induced)[hydroxyprogesterone (hormone replacement): hydroxyprogesterone]

ifosfamidecaution advised: combo may incr. ifosfamide active metabolite and toxic metabolite levels, incr. efficacy and risk of neurotoxicity (hepatic metab. induced, incr. active metabolite and toxic metabolite formation)

isotretinoincaution advised: combo may incr. risk of bone loss (additive effects)

kavacaution advised: combo may incr. risk of hepatotoxicity (additive toxicity)[kava: ava pepper, awa, intoxicating pepper, kao, kava (Piper methysticum), kawa, kew, Piper methysticum, sakau, tonga, yagona]

ketaminecaution advised: combo may decr. ketamine levels, efficacy (hepatic metab. induced)

levocetirizinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

levonorgestrel intrauterine devicecaution advised: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)

lidocaine topicalcontraindicated if <1 yo, otherwise caution advised: combo w/ topical lidocaine may incr. risk of methemoglobinemia (additive effects)[lidocaine topical: benzethonium chloride/lidocaine topical, hydrocortisone/lidocaine topical, lidocaine oronasopharyngeal, lidocaine topical, lidocaine urethral, lidocaine/epinephrine iontophoretic topical, lidocaine/prilocaine topical, lidocaine/tetracaine topical]

linezolidcaution advised: combo may decr. linezolid levels, efficacy (mechanism unknown, hepatic metab. possibly induced)

meperidinecaution advised: combo may decr. meperidine levels, analgesic efficacy, may incr. risk of normeperidine neurotoxicity (hepatic metab. induced, incr. toxic metabolite formation)

meprobamatecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

mirtazapinecaution advised: combo may decr. mirtazepine levels, effects (hepatic metab. induced)

mitotanecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

montelukastcaution advised: combo may decr. montelukast levels, efficacy (hepatic metab. induced)

morphine liposomalcaution advised: combo may incr. risk of CNS depression, profound sedation, hypotension, other adverse effects (additive effects)

nafarelin nasalcaution advised: combo may incr. risk of bone loss (additive effects)

nevirapinecaution advised: combo may decr. nevirapine levels, efficacy (hepatic metab. induced)

niacin/lovastatincaution advised: combo may decr. lovastatin levels, efficacy (hepatic metab. induced)

niacin/simvastatincaution advised: combo may decr. simvastatin levels, efficacy (hepatic metab. induced)

nitrites/sodium thiosulfatecaution advised: combo w/ nitrites may incr. risk of methemoglobinemia (additive effects)[nitrites/sodium thiosulfate: amyl nitrite/sodium nitrite/sodium thiosulfate, sodium nitrite/sodium thiosulfate]

nitroprussidecaution advised: combo may incr. risk of methemoglobinemia (additive effects)

olopatadine nasalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

oxycodonecaution advised, consider dose adjustment: combo may decr. oxycodone levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

oxycodone/ibuprofencaution advised, consider dose adjustment: combo may decr. oxycodone levels, efficacy;

incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

paclitaxelcaution advised: combo may decr. paclitaxel levels, efficacy (hepatic metab. induced)[paclitaxel: paclitaxel, paclitaxel nanoparticle albumin-bound]

peginterferon alfa 2bcaution advised: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

pimozidecaution advised: combo may decr. pimozide levels, efficacy; combo may incr. risk of CNS depression, psychomotor impairment; pimozide may lower seizure threshold (hepatic metab. induced; additive effects; antagonistic effects)

pramipexolecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

pregabalincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

progesterone (hormone replacement)caution advised: combo may decr. progesterone levels, efficacy (hepatic metab. induced)[progesterone (hormone replacement): progesterone micronized]

progesterone vaginal (hormone replacement)caution advised: combo may decr. progesterone levels, efficacy (hepatic metab. induced)[progesterone vaginal (hormone replacement): progesterone vaginal]

propofolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment; may decr. propofol levels, efficacy (additive effects; hepatic metab. induced)[propofol: fospropofol, propofol]

propoxyphenecaution advised: combo may decr. propoxyphene levels, efficacy, incr. active metabolite formation, risk of toxicity (hepatic metab. induced)[propoxyphene: propoxyphene hydrochloride, propoxyphene napsylate]

quetiapinecaution advised: combo may decr. quetiapine levels, efficacy (clearance increased)

quinine sulfatecaution advised: combo may decr. quinine levels, efficacy (hepatic metab. induced)

ramelteoncaution advised: combo may decr. ramelteon levels, efficacy (hepatic metab. induced)

risperidonecaution advised: combo may decr. risperidone levels, efficacy (hepatic metab. induced)

romidepsincaution advised: combo may decr. romidepsin levels, efficacy (hepatic metab. induced)

ropinirolecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

rotigotine transdermalcaution advised: combo may incr. phenytoin levels, risk of toxicity; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. inhibited; additive effects)

ruxolitinibcaution advised: combo may decr. ruxolitinib levels, efficacy, may incr. active metabolite formation, risk of adverse effects (hepatic metab. induced)

selegilinecaution advised: combo may decr. selegiline levels, efficacy (hepatic metab. induced)

selegiline transdermalcaution advised: combo may decr. selegiline levels, efficacy (hepatic metab. induced)

sildenafilcaution advised: combo may decr. sildenafil levels, efficacy (hepatic metab. induced)

sodium oxybatecaution advised: combo may incr. risk of CNS depression, other adverse effects (additive effects)

solifenacincaution advised: combo may decr. solifenacin levels, efficacy (hepatic metab. induced)

sorafenibcaution advised, monitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects; decr. sorafenib levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

streptozocincaution advised: combo may decr. streptozocin efficacy (mechanism unknown)

sufentanilcaution advised: combo may decr. sufentanil efficacy (hepatic metab. induced)

tamoxifencaution advised: combo may decr. tamoxifen and active metabolite levels, efficacy (hepatic metab. induced)

tapentadolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

teniposidecaution advised: combo may decr. teniposide levels, efficacy (hepatic metab. induced)

tetrabenazinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

thiotepacaution advised: combo may decr. thiotepa levels, efficacy; may incr. thiotepa active metabolite levels, risk of toxicity (hepatic metab. induced)

toremifenecaution advised: combo may decr. toremifene levels, efficacy (hepatic metab. induced)

tricyclic antidepressantscaution advised: combo w/ TCAs may alter seizure control; combo may incr. risk of CNS depression, psychomotor impairment (decreased seizure threshold; additive effects)[tricyclic antidepressants: amitriptyline, amoxapine, chlordiazepoxide/amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, perphenazine/amitriptyline, protriptyline, trimipramine]

vemurafenibcaution advised: combo may decr. vemurafenib levels, efficacy (hepatic metab. induced)

vinca alkaloidscaution advised: combo may decr. vinca alkaloid levels, efficacy (hepatic metab. induced)[vinca alkaloids: vinblastine, vincristine, vinorelbine]

zaleploncaution advised: combo may decr. zaleplon levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

zolpidemcaution advised: combo may decr. zolpidem levels, efficacy (hepatic metab. induced)

zonisamidecaution advised: combo may decr. zonisamide levels, efficacy (hepatic metab. induced)

Adverse Reactions

Serious Reactions

ventricular fibrillation (IV use) hypotension, severe (IV use)

cardiovascular collapse (IV use)

AV conduction abnormalities (IV use)

hepatotoxicity

thrombocytopenia

leukopenia

agranulocytosis

pancytopenia

anemia, megaloblastic

exfoliative dermatitis

Stevens-Johnson syndrome

toxic epidermal necrolysis

rash w/ eosinophilia and systemic sx

tissue necrosis (IV use)

purple glove syndrome (IV use)

anaphylaxis

lymphoma

lupus erythematosus

osteomalacia

toxic delirium

suicidality

periarteritis nodosa

Common Reactions

nausea vomiting

rash

nystagmus

ataxia

slurred speech

dizziness

confusion

paresthesia

blurred vision

somnolence

constipation

headache

insomnia

gingival hyperplasia

taste changes

tremor

lymphadenopathy

coarse facies

hyperglycemia

osteomalacia

phlebitis (IV use)

Peyronie dz

Safety/Monitoring

Pregnancy: D (Positive evidence of human fetal risk; maternal benefit may outweigh fetal risk in serious or life-threatening situations; see pkg insert for drug-specific recs)

Lactation: Probably Safe (Limited information in animals and/or humans demonstrates no risk/minimal risk of adverse effects to infant/breast milk production; caution advised)

Therapeutic Drug Levels 10-20 mcg/mL (total), 1-2 mcg/mL (free); Toxic Levels: >20 mcg/mL (total), >2 mcg/mL (free); Timing: 24h after PO load, or just prior to next dose; Time to Steady State: 7-10 days, highly variable

Monitoring Parameters Cr at baseline; CBC; LFTs; folate; serum drug levels periodically and if change dosage form/brand; dental exam q3mo; s/sx depression, behavior changes, suicidality

Look/Sound-Alike Drug Names [from www.usp.org]

phenytoin confused with: phenylephrine

phenytoin sodium confused with: Feldene; fluconazole; fosphenytoin; nystatin; phenazopyridine; phenobarbital; phytonadione

Pharmacology

Metabolism: liver; CYP450: 2C9 (primary), 2C19 substrate; 2B6, 2C9/19, 3A4 inducer

Excretion: bile, urine; Half-life: 22h

Subclass: Seizure Disorders

Mechanism of Actionmodulates neuronal voltage-dependent sodium and calcium channels

Manufacturer/Pricing

Manufacturer: Mylan Pharmaceuticals, Inc.

DEA/FDA: Rx: (Requires prescription; not a controlled substance)

Approximate Retail Price

from  www.drugstore.com

capsule:

200 mg (30 ea): $42.89 300 mg (100 ea): $163.89

Patient Education

Nombre Genérico: phenytoin (oral)

Nombres de las Marcas: Dilantin, Dilantin Infatabs, Dilantin-125, Phenytek

¿Cuál es la información más importante que debo saber sobre phenytoin?

Usted no debe tomar phenytoin si usted también está tomando delavirdine (Rescriptor), o si es alérgico a phenytoin, ethotoin (Peganone), fosphenytoin (Cerebyx), o mephenytoin (Mesantoin).

Si usted está embarazada, NO EMPIECE A TOMAR phenytoin salvo que su médico le haya indicado hacerlo. Phenytoin puede hacer daño al bebé nonato, pero tener una convulsión cuando está embarazada le puede hacer daño a la madre y al bebé. Si usted queda embarazada mientras está tomando phenytoin, NO DEJE DE TOMAR la medicina sin el consejo de su médico. Control de las convulsiones es muy importante durante el embarazo y el beneficio de evitar convulsiones puede sobrepasar el riesgo que presenta tomar phenytoin.

Usted puede tener pensamientos de suicidio cuando empiece a tomar esta medicina. Su médico necesitará examinarlo con regularidad. No falte a las visitas médica establecidas por su médico.

Informe a su médico de algún síntoma nuevo o que empeora, como: cambios del humor o del comportamiento, depresión, ansiedad, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o de físico), o tiene pensamientos de suicidio o de querer hacerse daño.

¿Qué es phenytoin?

Phenytoin es una droga antiepiléptica, también conocida como un anticonvulsivante. Funciona reduciendo los impulsos en el cerebro que causan convulsiones.

Phenytoin se usa para el control de las convulsiones. Phenytoin no trata todas los tipos de convulsiones, y su médico determinará si es la medicina correcta para usted.

Phenytoin puede también usarse para fines no mencionados en esta guía del medicamento.

¿Qué debería discutir con el profesional del cuidado de la salud antes de usar phenytoin?

Usted no debe tomar phenytoin si usted también está tomando delavirdine (Rescriptor), o si es alérgico a phenytoin, ethotoin (Peganone), fosphenytoin (Cerebyx), o mephenytoin (Mesantoin).

Para asegurarse que usted puede tomar phenytoin de forma segura, dígale a su médico si usted tiene cualquiera de estas otras condiciones:

enfermedad del hígado;

lupus;

diabetes;

deficiencia de la vitamina D o cualquier otra condición que desgasta los huesos;

porfiria (un trastorno genético de enzima que causa síntomas que afectan la piel o el sistema nervioso); o

si usted consume gran cantidad de alcohol.

Usted puede tener pensamientos de suicidio mientras toma este medicamento. Dígale a su médico si usted tiene síntomas de la depresión o pensamientos de suicidio nuevos o que empeoran durante los primeros meses del tratamiento, o cuando tenga cambios en su dosis.

Su familia o quienes lo atiendan también deben mantenerse alertas a los cambios en su humor o síntomas. Su médico necesitará examinarlo con regularidad. No falte a las visitas médicas establecidas por su médico.

Los pacientes con antepasados de origen Asiático pueden tener un riesgo más alto de desarrollar una reacción a la piel, rara, pero de gravedad con phenytoin. Su médico puede recomendar pruebas de la sangre antes de que empiece la medicina para determinar su riesgo a tener esta reacción.

Categoría D del embarazo por la FDA. Phenytoin le puede hacer daño al bebé nonato, pero tener una convulsión cuando está embarazada le puede hacer daño a la madre y al bebé.

Si usted está embarazada, NO EMPIECE A TOMAR phenytoin salvo que su médico le haya indicado. Si usted queda embarazada mientras está tomando phenytoin, NO DEJE DE TOMAR la medicina sin el consejo de su médico.

El control de las convulsiones es muy importante durante el embarazo. El beneficio de evitar convulsiones puede sobrepasar el riesgo que presenta tomar phenytoin. Siga las instrucciones de su médico acerca de tomar phenytoin durante su embarazo.

Phenytoin puede hacer las pastillas anticonceptivas menos efectivas. Para prevenir el embarazo mientras toma phenytoin, use un método de control de natalidad no hormonal (como el condón o diafragma con espermicida).

Phenytoin puede pasar a la leche materna y causarle daño al bebé lactante. Usted no debe amamantar mientras está usando phenytoin.

¿Cómo debo tomar phenytoin?

Tómelo exactamente cómo lo haya recetado su médico. No lo tome en cantidades mayores o menores, o por más tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripción.

No triture, mastique, rompa, o abra una cápsula de liberación extendida. Tráguelas enteras. Romper o abrir la píldora puede causar que mucha medicina pase al cuerpo de inmediato. No use ninguna cápsula que ha cambiado de color. Llame a su médico para una nueva prescripción.

Agite bien la suspensión oral (líquida) antes de medir una dosis. Mida el líquido con una cucharita o taza de medición, no lo haga con una cuchara normal. Si no tiene con que medir su dosis, pídale una a su farmacéutico.

Para estar seguro de que este medicamento está ayudando su condición, tal vez se necesite examinar su sangre con frecuencia. También puede ser que necesite exámenes de sangre cuando cambie de una presentación de phenytoin a otra. Visite a su médico con regularidad.

Si está tomando phenytoin para el tratamiento de convulsiones, siga tomando la medicina aunque se sienta bien. Usted puede tener un aumento en convulsiones si deja de tomar phenytoin. No cambie su dosis de phenytoin sin la previa aprobación de su médico. Dígale a su médico si le parece que su medicina ha dejado de funcionar como lo hacia para el tratamiento de su condición.

Lleve con usted una tarjeta de identificación que indique que usted está tomando phenytoin. Cualquier proveedor del cuidado médico que lo trate debería saber que usted esta usando una medicina para el control de convulsiones.

Guarde a temperatura ambiente lejos de la humedad, luz, y calor.

¿Qué sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sáltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome más medicina para alcanzar la dosis pasada.

¿Qué sucedería en una sobredosis?

Busque atención médica de emergencia o llame a la línea de Poison Help al 1-800-222-1222. La sobredosis de phenytoin puede ser fatal. Los síntomas de sobredosis pueden incluir movimientos espasmódicos de los ojos, arrastre de las palabras al hablar, perdida del balance,

temblores, rigidez muscular o debilidad, náusea, vómito, sentir que se puede desmayar, desmayo, y respiración lenta o no profunda.

¿Qué debo evitar mientras uso phenytoin?

Evite beber alcohol mientras esté tomando phenytoin. Consumir alcohol puede aumentar sus niveles de phenytoin en la sangre y puede aumentar los efectos secundarios. Consumir alcohol diariamente puede disminuir sus niveles de phenytoin en la sangre, lo que puede aumentar su riesgo de convulsiones.

Evite tomar antiácidos al mismo tiempo que toma phenytoin. Los antiácidos pueden hacer más difícil para que su cuerpo pueda absorber la medicina.

Phenytoin puede perjudicar su pensamiento o reacciones. Tenga cuidado si usted conduce un vehículo o tenga que hacer algo que demande se mantenga alerta.

¿Cuáles son los efectos secundarios posibles de phenytoin?

Busque atención médica de emergencia si usted tiene alguno de estos síntomas de una reacción alérgica: ronchas; dificultad para respirar; hinchazón de su cara, labios, lengua, o garganta. Es más probable que tenga una reacción alérgica si es de raza Americana-Africana.

Informe a su médico de algún síntoma nuevo o que empeora, como: cambios del humor o del comportamiento, depresión, ansiedad, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o de físico), o tiene pensamientos de suicidio o de querer hacerse daño.

Llame a su médico de inmediato si usted tiene un efecto secundario grave como:

fiebre, glándulas hinchadas, dolor de cuerpo, síntomas de la gripe; sarpullido, moretones o sangrado fácil, hormigueo severo, entumecimiento, dolor,

debilidad muscular;

dolor en la parte superior del estómago, pérdida del apetito, orina oscura, ictericia (color amarillo de la piel u ojos);

dolor de pecho, ritmo cardíaco irregular, sensación de que le falta aire al respirar;

confusión, náusea y vómito, hinchazón, ganancia de peso rápida, orinar menos de lo usual o nada en absoluto;

tos nueva o que empeora con fiebre, dificultad para respirar;

temblor (sacudidas que no puede controlar), movimientos musculares inquietos en sus ojos, lengua, quijada, o cuello;

color de piel con parches, manchas rojas, o un sarpullido en forma de mariposa sobre sus mejillas y nariz (que empeora con la luz del sol); o

reacción severa de la piel -- fiebre, dolor de garganta, hinchazón en su cara o lengua, quemazón en sus ojos, dolor de la piel, seguido por un sarpullido rojo o púrpura que se extiende (especialmente en la cara o la parte superior del cuerpo) y causa ampollas y descamación.

Efectos secundarios de menor gravedad pueden incluir:

habla arrastrado, perdida del balance o coordinación; encías hinchadas o adoloridas; o

dolor de cabeza, nerviosismo, o problemas para dormir (insomnio).

Esta lista no menciona todos los efectos secundarios y puede ser que ocurran otros. Llame a su médico para consejos médicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

¿Qué otras drogas afectarán a phenytoin?

Varias drogas pueden tener interacciones con phenytoin. La lista que se presenta abajo no incluye todas las drogas. Dígale a su médico si usted está usando:

antibióticos como cycloserine (Seromycin), doxycycline (Doryx, Vibramycin, Adoxa), isoniazid (para tratar tuberculosis), linezolid (Zyvox), rifampin (Rimactane, Rifadin, Rifamate), o sulfas (Bactrim, Septra, Sulfatrim, SMX-TMP, y otras);

un antidepresivo (como Elavil, Vanatrip, Limbitrol, Sinequan, Silenor, Pamelor, Paxil, Zoloft, Desyrel, y otras);

aspirin u otros salicilatos;

pastillas para el control de la natalidad o terapia de reemplazo hormonal;

un anticoagulante como warfarin (Coumadin, Jantoven);

ciertos sedantes (Librium, Librax, Limbitrol, Valium) o antidepresivos (Desyrel, Luvox, Zoloft, Prozac, Rapiflux, Sarafem, Selfemra, Symbyax);

medicamento para el corazón como amiodarone (Cordarone, Pacerone), digoxin (digitalis, Lanoxin), furosemide (Lasix), o quinidine (Quin-G);

prochlorperazine (Compazine, Compro), promethazine (Pentazine, Phenergan, Anergan, Antinaus), y otras fenotiazinas;

esteroides (prednisone y otras);

medicamento para convulsiones (como Carbatrol, Equetro, Tegretol, Solfoton, Depakene, o Depakote);

medicinas para reducir el ácido del estómago (como Tagamet, Prilosec, Zegerid, Zantac, Pepcid, o Axid; o

theophylline (Elixophyllin, Theo-Dur, Theo-Bid, Theolair, Uniphyl).

Esta lista no incluye todas las drogas y hay muchas otras drogas que pueden tener interacciones con phenytoin. Dígale a su médico acerca de todas los medicamentos que usted usa. Incluya los productos que se obtienen con o sin receta, vitaminas, y productos herbarios. No empiece un nuevo medicamento sin primero decirle a su médico. Mantenga una lista de todas sus medicinas y muéstresela a cualquier profesional de la salud que lo atienda.

¿Dónde puedo obtener más información?

Su farmacéutico le puede dar más información acerca de phenytoin (fenitoina).

Drug

phenytoingeneric

Entire Monograph

Black Box Warnings

Cardiovascular Risk with Rapid Infusion

IV infusion should not exceed 50 mg/min in adults or 1-3 mg/kg/min (or 50 mg/min, whichever is slower) in peds pts; incr. risk severe hypotension and cardiac arrhythmias above recommended infusion rate, but events also reported at or below recommended rate; monitor cardiac adverse events during and after IV infusion; IV infusion rate reduction or D/C may be necessary; EDITORIAL NOTE: expert guidelines suggest slower rates of 25-50 mg/min (healthy adults), 10-20 mg/min (elderly or cardiac dz), <1 mg/kg/min (peds pts), and 0.5 mg/kg/min (neonates) may decr. risk of tissue or vascular injury, hypotension, or other adverse events

Adult Dosing

Dosage forms:  100,200,300 ER; 125/5 mL; IM; IV

Special Note

[formulation clarification]Info: phenytoin ER caps contain 8% less drug than chewable tabs and susp; monitor closely and consider dose adjustment if switching between products

status epilepticus

[initial tx]Dose: 15-20 mg/kg IV x1; Info: may give additional 10 mg/kg IV x1 after 20min if no response to initial dose; begin maint. dose 12h after loading dose

[maintenance tx]Dose: 100 mg PO/IV q6-8h; Info: adjust dose based on tx response and serum levels

seizure disorder

[extended-release form]Dose: 300-400 mg/day ER PO div bid-tid; Max: 400 mg/dose ER; Alt: 4-7 mg/kg/day ER PO div bid-tid; Info: may consider load of 15-20 mg/kg ER PO div in 3 doses 2-4h apart; adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs; if stable on bid-tid ER dosing, then may switch to qd ER dosing; do not open/crush/chew

[immediate-release form]Dose: 300-400 mg/day PO/IV div bid-tid; Max: 400 mg/dose; Alt: 4-7 mg/kg/day PO/IV div bid-tid; Info: may consider load of 15-20 mg/kg PO/IV div in 3 doses 2-4h apart; adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs

seizure prophylaxis, neurosurgery-assoc.

[IV route]Dose: 4-6 mg/kg/day IV div bid-tid; Start: load 10-20 mg/kg IV div in 3 doses 2-4h apart; Max: 400 mg/dose; Info: IV route preferred to IM route

[IM route]Dose: 100-200 mg IM q4h; Max: x1wk; Alt: give 150% of usual daily PO dose by IM route div q4h; Info: decr. usual PO dose by 50% for same duration as IM was used when converting back from IM to PO

renal dosing

[adjust dose amount]renal impairment: do not give oral loading regimen; HD/PD: no supplement

hepatic dosing

[adjust dose amount]hepatic impairment: do not give oral loading regimen

Peds Dosing

Dosage forms:  100,200,300 ER; 125/5 mL; IV

Special Note

[formulation clarification]Info: phenytoin ER caps contain 8% less drug than chewable tabs and susp; monitor closely and consider dose adjustment if switching between products

status epilepticus

[15-20 mg/kg IV x1]

Max: 1500 mg/day; Info: may give additional 10 mg/kg IV x1 after 20min if no response to initial dose; begin maint. dose 12h after loading dose

seizure disorder

[immediate-release form, <6 mo]Dose: 5-8 mg/kg/day PO/IV div bid-tid; Start: 5 mg/kg/day PO/IV div bid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs

[immediate-release form, 6 mo-4 yo]Dose: 8-10 mg/kg/day PO/IV div bid-tid; Start: 5 mg/kg/day PO/IV div bid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs

[immediate-release form, 4-7 yo]Dose: 7.5-9 mg/kg/day PO/IV div bid-tid; Start: 5 mg/kg/day PO/IV div bid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs

[immediate-release form, 7-10 yo]Dose: 7-8 mg/kg/day PO/IV div bid-tid; Start: 5 mg/kg/day PO/IV div bid-tid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs

[immediate-release form, 10-16 yo]Dose: 6-7 mg/kg/day PO/IV div bid-tid; Start: 5 mg/kg/day PO/IV div bid-tid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs

[immediate-release form, >16 yo]see Adult Dosing

[extended-release form, 7-10 yo]Dose: 7-8 mg/kg/day ER PO div bid-tid; Start: 5 mg/kg/day ER PO div bid-tid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs; if stable on bid-tid ER dosing, then may switch to qd ER dosing; do not open/crush/chew

[extended-release form, 10-16 yo]Dose: 6-7 mg/kg/day ER PO div bid-tid; Start: 5 mg/kg/day ER PO div bid-tid; Info: adjust dose based on tx response and serum levels; if div doses unequal, give larger dose qhs; if stable on bid-tid ER dosing, then may switch to qd ER dosing; do not open/crush/chew

[extended-release form, >16 yo]see Adult Dosing

renal dosing

[no adjustment]

hepatic dosing

[adjust dose amount]hepatic impairment: decr. dose, amount not defined

Contraindications/Cautions

hypersens. to drug/class/compon. SA block (IM or IV use)

2nd or 3rd degree AV block (IM or IV use)

sinus bradycardia (IM or IV use)

Adams-Stokes syndrome (IM or IV use)

caution if hypotension (IM or IV use)

caution if cardiovascular dz (IM or IV use)

caution if renal impairment

caution if hepatic impairment

caution if diabetes mellitus

caution if pregnancy

caution in elderly pts

caution if porphyria

caution if alcohol use

caution if thyroid dz

avoid abrupt withdrawal

caution if HLA-B*1502-positive

caution if depression or hx

Drug Interactions

Contraindicated

boceprevircontraindicated: combo may decr. boceprevir levels, efficacy (hepatic metab. induced)

delavirdinecontraindicated: combo may decr. delavirdine levels, efficacy (hepatic metab. induced)

emtricitabine/rilpivirine/tenofovir disoproxilcontraindicated: combo may decr. rilpivirine levels, efficacy (hepatic metab. induced)

etravirinecontraindicated: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

lopinavir/ritonavircontraindicated w/ once daily lopinavir/ritonavir; use alternative or weigh risk/benefit w/ other regimens; monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

lurasidonecontraindicated: combo may decr. lurasidone levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

praziquantelcontraindicated; D/C phenytoin 4wk prior to praziquantel course, may restart phenytoin 1 day after last dose praziquantel: combo may decr. praziquantel levels, efficacy (hepatic metab. induced)

ranolazinecontraindicated: combo may decr. ranolazine levels, efficacy (hepatic metab. induced)

rilpivirinecontraindicated: combo may decr. rilpivirine levels, efficacy (hepatic metab. induced)

Avoid/Use Alternative

acetaminophen/codeineuse alternative or limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy; incr. risk of CNS and respiratory depression, psychomotor impairment (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

axitinibavoid combo: combo may decr. axitinib levels, efficacy (hepatic metab. induced)

bortezomibavoid combo: combo may decr. bortezomib levels, efficacy (hepatic metab. induced)

bosutinibavoid combo: combo may decr. bosutinib levels, efficacy (hepatic metab. induced)

cabazitaxelavoid combo: combo may decr. cabazitaxel levels, efficacy (hepatic metab. induced)

calcium channel blockers, dihydropyridinesuse alternative or monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)[calcium channel blockers, dihydropyridines: amlodipine, amlodipine/benazepril, felodipine, isradipine, nicardipine, nifedipine, nimodipine, nisoldipine]

calcium channel blockers, othersuse alternative or monitor for efficacy: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)[calcium channel blockers, others: diltiazem, trandolapril/verapamil, verapamil]

cobicistatavoid combo: combo may decr. cobicistat levels, efficacy (hepatic metab. induced)[cobicistat: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil]

contraceptives, oral combocaution advised; use additional non-hormonal or alternative contraception: combo may result in loss of seizure control; combo may decr. hormonal contraceptive levels, efficacy (estrogen-induced fluid retention; hepatic metab. induced)[contraceptives, oral combo: desogestrel/ethinyl estradiol, drospirenone/ethinyl estradiol, drospirenone/ethinyl estradiol/levomefolate, estradiol valerate/dienogest, ethynodiol/ethinyl estradiol, levonorgestrel/ethinyl estradiol, norethindrone/ethinyl estradiol, norethindrone/mestranol, norgestimate/ethinyl estradiol, norgestrel/ethinyl estradiol]

contraceptives, oral progestinuse additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)[contraceptives, oral progestin: norethindrone]

contraceptives, other combocaution advised; use additional non-hormonal or alternative contraception: combo may result in loss of seizure control; combo may decr. hormonal contraceptive levels, efficacy (estrogen-induced fluid retention; hepatic metab. induced)[contraceptives, other combo: etonogestrel/ethinyl estradiol vaginal, norelgestromin/ethinyl estradiol transdermal]

crizotinibavoid combo or use alternative: combo may decr. crizotinib levels, efficacy (hepatic metab. induced)

deferasiroxavoid combo or consider incr. initial deferasirox dose to 30 mg/kg/day, monitor ferritin and phenytoin levels: combo may decr. deferasirox efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; hepatic metab. inhibited)

dopamineuse alternative or monitor BP: combo w/ IV phenytoins may incr. risk of severe hypotension (mechanism unknown, possible additive effects)

dronedaroneavoid combo: combo may decr. dronedarone levels, efficacy (hepatic metab. induced)

elvitegraviravoid combo or use alternative: combo may decr. levels, efficacy of both drugs (hepatic

metab. induced)[elvitegravir: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil]

enzalutamideavoid combo: combo may decr. levels of both drugs, efficacy (hepatic metab. induced)

erlotinibuse alternative or consider incr. erlotinib dose >150 mg/day: combo may decr. erlotinib levels (hepatic metab. induced)

etonogestrel subdermal implantuse additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)

everolimusavoid combo or adjust dose based on indication; incr. everolimus dose up to 20 mg/day in breast CA, PNET, renal cell CA, or renal angiomyolipoma w/ TSC pts; double everolimus dose and monitor levels in SEGA pts; monitor levels in transplant pts: combo may decr. everolimus levels, efficacy (hepatic metab. induced)

ginkgo bilobaavoid consumption of raw ginkgo seeds: combo may decr. anticonvulsant efficacy (antagonistic effects, high dose ginkgotoxin may cause seizures)[ginkgo biloba: Eun-haeng, fossil tree, ginkgo (Ginkgo biloba), Ginkgo biloba, ginkyo, icho, ityo, Japanese silver apricot, kew tree, maidenhair tree, salisburia, silver apricot]

hydrocodone/acetaminophenuse alternative or limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy; incr. risk of CNS and respiratory depression, psychomotor impairment (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

irinotecanavoid combo or use alternative; consider switch to non-enzyme inducing anticonvulsant >2wk prior to irinotecan start: combo may decr. irinotecan and active metabolite levels, efficacy (hepatic metab. induced)

ivacaftoravoid combo: combo may decr. ivacaftor levels, efficacy (hepatic metab. induced)

ixabepiloneuse alternative: combo may decr. ixabepilone levels, efficacy (hepatic metab. induced)

lapatinibavoid combo or consider incr. lapatinib dose gradually up to 4500 mg/day; monitor phenytoin levels: combo may decr. lapatinib levels, efficacy; may incr. phenytoin levels, risk of adverse effects, toxicity (hepatic metab. induced; hepatic metab. inhibited)

levonorgestreluse alternative non-hormonal contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)

linagliptinuse alternative: combo may decr. linagliptin levels, efficacy (hepatic metab. induced, p-glycoprotein induced, antagonistic effects)

linagliptin/metforminuse alternative: combo may decr. linagliptin levels, efficacy (hepatic metab. induced, P-glycoprotein induced)

local anestheticsavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)[local anesthetics: bupivacaine, bupivacaine liposomal, chloroprocaine, lidocaine, mepivacaine, procaine, ropivacaine]

local anesthetics/epinephrineavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)[local anesthetics/epinephrine: articaine/epinephrine]

medroxyprogesterone acetateuse additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)

methotrexateuse alternative or monitor efficacy, toxicity, levels: combo may incr. methotrexate toxicity and decr. efficacy; may decr. phenytoin levels, efficacy (mechanism unknown; absorption decreased)

mifepristoneavoid combo if daily mifepristone use; caution advised if pregnancy termination use: combo may decr. mifepristone levels, efficacy (hepatic metab. induced)

milk thistleavoid combo or monitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects (hepatic metab. inhibited)[milk thistle: Carduus marianum, holy thistle, Lady's thistle, legalon, Marian thistle, Mary thistle, milk thistle (Silybum marianum), silibinin, silybin, Silybum marianum, silymarin, St. Mary thistle]

nilotinibavoid combo or consider incr. nilotinib dose and monitor ECG, phenytoin levels: combo may incr. phenytoin levels, risk of toxicity; may decr. phenytoin or nilotinib levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

oxycodone/acetaminophenuse alternative or limit acetaminophen <2 g/day: combo may decr. oxycodone levels, efficacy; incr. risk of acetaminophen toxicity, decr. efficacy; incr. risk of CNS and respiratory depression, psychomotor impairment (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

pazopanibcontraindicated if chronic use of strong CYP3A4 inducer, otherwise avoid combo or use alternative: combo may decr. pazopanib levels, efficacy (hepatic metab. induced)

pentazocine/acetaminophenuse alternative or limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy; incr. risk of CNS and respiratory depression, psychomotor impairment (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

posaconazoleweigh risk/benefit, monitor phenytoin levels: combo may decr. posaconazole levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. altered)

rivaroxabanavoid combo: combo may decr. rivaroxaban levels, efficacy (hepatic metab. induced, P-glycoprotein induced)

roflumilastavoid combo: combo may decr. roflumilast levels, efficacy (hepatic metab. induced)

sunitinibuse alternative or consider incr. sunitinib dose to max 87.5 mg/day in GIST or RCC pts and max 62.5 mg/day in PNET pts: combo may decr. sunitinib levels, efficacy (hepatic metab. induced)

tadalafilavoid combo in pulmonary HTN pts; caution advised for ED pts: combo may decr. tadalafil levels, efficacy (hepatic metab. induced)

telapreviravoid combo or monitor phenytoin levels and titrate dose: combo may alter phenytoin levels, decr. efficacy or incr. toxicity; may decr. telaprevir levels, efficacy (hepatic metab. altered; hepatic metab. induced, p-glycoprotein induced)

temsirolimusavoid combo or consider incr. temsirolimus dose to 50 mg/wk: combo may decr. temsirolimus and sirolimus levels, efficacy (hepatic metab. induced)

ticagreloravoid combo: combo may decr. ticagrelor levels, efficacy (hepatic metab. induced)

tolvaptanavoid combo or consider incr. tolvaptan dose: combo may decr. tolvaptan levels, efficacy (hepatic metab. induced)

tramadolavoid combo: combo may decr. tramadol levels, efficacy; may incr. risk of CNS depression, psychomotor impairment, alter seizure control (hepatic metab. induced; additive effects, decr. seizure threshold)

tramadol/acetaminophenuse alternative: combo may incr. risk of acetaminophen toxicity, decr. tramadol levels and efficacy; incr. risk of CNS depression, psychomotor impairment; tramadol may decr. seizure threshold (hepatic metab. induced; incr. toxic acetaminophen metabolite formation; additive effects)

ulipristaluse alternative non-hormonal contraception: combo may decr. ulipristal levels, contraceptive efficacy (hepatic metab. induced)

vandetanibavoid combo: combo may decr. vandetanib levels, efficacy (hepatic metab. induced)

Monitor/Modify Tx

acarbosemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

acetaminophen/aspirincaution advised, especially w/ high dose aspirin or salicylates, monitor phenytoin levels; limit acetaminophen <2 g/day: combo w/ aspirin may incr. phenytoin levels, risk of toxicity; combo may incr. risk of acetaminophen toxicity, decr. efficacy (protein binding displacement; hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/aspirin/caffeinecaution advised, especially w/ high dose aspirin or salicylates, monitor phenytoin levels; limit acetaminophen <2 g/day: combo w/ aspirin may incr. phenytoin levels, risk of toxicity; combo may decr. caffeine levels, efficacy; combo may incr. risk of acetaminophen toxicity, decr. efficacy (protein binding displacement; hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/caffeinecaution advised; limit acetaminophen <2 g/day: combo may decr. caffeine levels, efficacy; combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/caffeine/CNS depressant comboscaution advised, limit acetaminophen <2 g/day: combo may decr. caffeine levels, efficacy; may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab.

induced; incr. toxic acetaminophen metabolite formation)[acetaminophen/caffeine/CNS depressant combos: acetaminophen/caffeine/dihydrocodeine, butalbital/acetaminophen/caffeine, butalbital/acetaminophen/caffeine/codeine]

acetaminophen/chlorpheniraminecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/chlorpheniramine/dextromethorphancaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/chlorpheniramine/dextromethorphan/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/chlorpheniramine/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/dextromethorphancaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/dextromethorphan/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophen/dextromethorphan/phenylephrine: acetaminophen/dextromethorphan/phenylephrine, acetaminophen/dextromethorphan/phenylephrine/guaifenesin]

acetaminophen/dextromethorphan/pseudoephedrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophen/dextromethorphan/pseudoephedrine: acetaminophen/dextromethorphan/pseudoephedrine/guaifenesin]

acetaminophen/diphenhydraminecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/diphenhydramine/dextromethorphancaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/diphenhydramine/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/doxylamine/dextromethorphancaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/doxylamine/dextromethorphan/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/doxylamine/dextromethorphan/pseudoephedrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/doxylamine/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/magnesium salicylate/pamabromcaution advised, especially w/ high dose aspirin or salicylates, monitor phenytoin levels; limit acetaminophen <2 g/day: combo w/ salicylates may incr. phenytoin levels, risk of toxicity; combo may incr. risk of acetaminophen toxicity, decr. efficacy (protein binding displacement; hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/pamabromcaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced, incr. toxic metabolite formation)

acetaminophen/pheniramine/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/phenylephrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophen/phenylephrine: acetaminophen/phenylephrine, acetaminophen/phenylephrine/guaifenesin]

acetaminophen/pseudoephedrinecaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophen/pseudoephedrine: acetaminophen/pseudoephedrine/guaifenesin]

acetaminophenscaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)[acetaminophens: acetaminophen, acetaminophen rectal, acetaminophen/guaifenesin, isometheptene/dichloralphenazone/acetaminophen]

acyclovirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown)

aliskiren/amlodipinemonitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)

aliskiren/amlodipine/hydrochlorothiazidemonitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)

amiodaronemonitor levels, efficacy: combo may incr. phenytoin levels, risk of toxicity; decr. amiodarone levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

amlodipine/ARB combosmonitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)[amlodipine/ARB combos: amlodipine/olmesartan, amlodipine/valsartan, telmisartan/amlodipine]

amlodipine/ARB/thiazide combosmonitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)[amlodipine/ARB/thiazide combos: amlodipine/valsartan/hydrochlorothiazide, olmesartan/amlodipine/hydrochlorothiazide]

amlodipine/atorvastatinmonitor BP, cholesterol levels: combo may decr. both statin and calcium channel blocker levels, efficacy (hepatic metab. induced)

antacidsgive oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)[antacids: aluminum hydroxide, aluminum hydroxide/magnesium carbonate, aluminum hydroxide/magnesium hydroxide, aluminum hydroxide/magnesium hydroxide/simethicone, aluminum hydroxide/magnesium trisilicate, magnesium hydroxide]

aprepitantcaution advised, monitor efficacy: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)[aprepitant: aprepitant, fosaprepitant]

aripiprazoleadjust aripiprazole dose, may be doubled up to max 30 mg/day: combo may decr. aripiprazole levels, efficacy (hepatic metab. induced)

aspirincaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/caffeinecaution advised, especially w/ high dose aspirin or salicylates, monitor phenytoin levels: combo w/ aspirin may incr. phenytoin levels, risk of toxicity; combo may decr. caffeine levels, efficacy (protein binding displacement; hepatic metab. induced)

aspirin/calcium carbonategive oral phenytoin 2h before or 4h after oral calcium salts; caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo w/ calcium may decr. phenytoin levels, efficacy; combo w/ aspirin may incr. phenytoin levels, risk of toxicity (absorption decreased; protein binding displacement)

aspirin/chlorpheniramine/dextromethorphancaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/chlorpheniramine/dextromethorphan/phenylephrinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/chlorpheniramine/phenylephrinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/diphenhydraminecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/dipyridamolecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/doxylamine/dextromethorphan/phenylephrinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/phenylephrinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

atazanavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

bexarotenecaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

bismuth subcitrate potassium/metronidazole/tetracyclinemonitor levels: combo w/ metronidazole may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

bismuth subsalicylate/metronidazole/tetracyclinemonitor levels: combo w/ metronidazole, salicylates may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited, protein binding displacement)

bosentancaution advised, monitor phenytoin levels: combo may decr. bosentan levels, decr. phenytoin levels (hepatic metab. induced)

butalbital/acetaminophencaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced, incr. toxic acetaminophen metabolite formation)

calcitriolmonitor efficacy; consider calcitriol dose adjustment: enzyme induction may decr. endogenous calcitriol levels, resulting in incr. supplemental calcitriol requirements (hepatic metab. induced)

calcium carbonate/magnesium hydroxidegive oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)[calcium carbonate/magnesium hydroxide: calcium carbonate/magnesium hydroxide, calcium carbonate/magnesium hydroxide/simethicone]

calcium saltsgive phenytoin 2h before or 4h after oral calcium salts: combo may decr. phenytoin levels, efficacy (absorption decreased)[calcium salts: calcium acetate, calcium carbonate, calcium carbonate/simethicone, calcium chloride, calcium citrate, calcium gluconate, risedronate/calcium carbonate]

capecitabinemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown)

carbamazepinemonitor levels: combo may alter levels of both drugs; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

carisoprodol/aspirincaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

carisoprodol/aspirin/codeinecaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. risk of CNS depression, psychomotor impairment; combo may incr. phenytoin levels, risk of toxicity (additive effects; protein binding displacement)

carvedilolmonitor efficacy: combo may decr. carvedilol levels, efficacy (hepatic metab. induced)

caspofunginconsider incr. caspofungin dose to 70 mg/day in adults, 70 mg/m^2 in peds: combo may decr. caspofungin levels, efficacy (hepatic metab. induced)

chloramphenicolmonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

cimetidinemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

cinacalcetmonitor iPTH, serum calcium: combo may decr. cinacalcet levels, efficacy (hepatic metab. induced)

ciprofloxacinmonitor levels: combo may incr. or decr. phenytoin levels (hepatic metab. altered)

clarithromycinmonitor phenytoin levels: combo may decr. clarithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown)

clopidogrelcaution advised, monitor phenytoin levels: may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

clozapinecaution advised, monitor for altered response to clozapine: combo may decr. clozapine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

CNS depressant/aspirin/caffeine comboscaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may decr. caffeine levels, efficacy; combo may incr. phenytoin levels, risk of toxicity (hepatic metab. induced; phenytoin protein binding displacement)[CNS depressant/aspirin/caffeine combos: butalbital/aspirin/caffeine, butalbital/aspirin/caffeine/codeine, dihydrocodeine/aspirin/caffeine]

colesevelamgive phenytoin >4h before; monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (absorption decreased)

cyclosporinemonitor levels: combo may decr. cyclosporine levels, efficacy (hepatic metab. induced)[cyclosporine: cyclosporine modified, cyclosporine non-modified]

darunavirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

diazepamcaution advised, monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity; may incr. risk of CNS depression, psychomotor impairment (mechanism unknown; additive effects)[diazepam: diazepam, diazepam rectal]

digoxinmonitor digoxin levels: combo may decr. digoxin levels, efficacy (P-glycoprotein induced)

disopyramidemonitor levels: combo may decr. disopyramide levels, efficacy (hepatic metab. induced)

disulfirammonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

doxorubicinsmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown)[doxorubicins: doxorubicin, doxorubicin liposomal]

efavirenzcaution advised, monitor phenytoin levels: combo may decr. efavirenz levels, efficacy; alter phenytoin levels (hepatic metab. altered)

efavirenz/emtricitabine/tenofovir disoproxilcaution advised, monitor phenytoin levels: combo w/ efavirenz may alter phenytoin levels; decr. efavirenz levels, efficacy (hepatic metab. altered)

erythromycinsmonitor phenytoin levels: combo may decr. erythromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown)[erythromycins: erythromycin base, erythromycin ethylsuccinate, erythromycin lactobionate, erythromycin stearate, erythromycin/sulfisoxazole]

ethosuximidemonitor ethosuximide levels: combo may decr. ethosuximide levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; mechanism unknown)

exemestaneadjust exemestane dose to 50 mg/day: combo may decr. exemestane levels, efficacy (hepatic metab. induced)

exenatidemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

ezogabineconsider incr. ezogabine dose; caution advised: combo may decr. ezogabine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

famotidine/calcium carbonate/magnesium hydroxidegive phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)

felbamatemonitor phenytoin levels, consider phenytoin dose reduction: combo may incr. phenytoin levels, risk of toxicity; decr. felbamate levels, efficacy (hepatic metab. altered)

fenofibratemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)[fenofibrate: fenofibrate, fenofibrate micronized, fenofibric acid]

fluconazolemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fluorouracilmonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fluoxetinemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fluvastatinmonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fluvoxaminemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

fosamprenavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

gefitinibconsider incr. gefitinib dose to 500 mg/day: combo may decr. gefitinib levels, efficacy (hepatic metab. induced)

gemfibrozilmonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

growth hormonemonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)[growth hormone: somatropin (recombinant)]

guanfacineconsider incr. guanfacine dose: combo may decr. guanfacine levels, efficacy (hepatic metab. induced)

imatinibincr. imatinib dose 50%, monitor response: combo may decr. imatinib levels, efficacy (hepatic metab. induced)

indinavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

influenza vaccinecaution advised, monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown, hepatic metab. possibly inhibited)[influenza vaccine: influenza intradermal vaccine, influenza vaccine]

insulinsmonitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects)[insulins: insulin aspart, insulin aspart protamine/insulin aspart, insulin detemir, insulin glargine, insulin glulisine, insulin lispro, insulin lispro protamine/insulin lispro, insulin NPH, insulin NPH/regular, insulin regular]

isoniazidmonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

itraconazolecaution advised, monitor efficacy: combo may decr. antifungal levels, efficacy (hepatic metab. induced)

ketoconazolecaution advised, monitor phenytoin levels: combo may decr. antifungal levels, efficacy; incr. phenytoin levels, risk of toxicity (hepatic metab. altered)

lamotriginecaution advised, adjust lamotrigine initial dose escalation; adjust maint. dose if hydantoin added or stopped: combo may decr. lamotrigine levels by 40% (hepatic metab. induced)

lansoprazole/amoxicillin/clarithromycinmonitor phenytoin levels: combo may decr. clarithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown)

leflunomidemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

leucovorincaution advised, monitor levels: combo may decr. anticonvulsant levels, efficacy (mechanism unknown)

levoleucovorincaution advised, monitor levels: combo may decr. anticonvulsant levels, efficacy (mechanism unknown)

liraglutidemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

lithiummonitor levels: combo may incr. lithium levels, risk of toxicity (mechanism unknown)

magnesium hydroxide/mineral oilgive oral phenytoin 2h before or 4h after: combo w/ antacids may decr. phenytoin levels, efficacy (absorption decreased)

magnesium saltsgive oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)[magnesium salts: magnesium citrate, magnesium gluconate, magnesium oxide, magnesium sulfate]

maravirocadjust maraviroc dose to 600 mg bid, unless combined w/ hepatic metab. inhibitor requiring decr. maraviroc dose of 150 mg bid: combo may decr. maraviroc levels, efficacy (hepatic metab. induced)

mefloquinemonitor levels, efficacy: combo may decr. levels, efficacy of both drugs (mechanism unknown, hepatic metab. possibly altered)

metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

metformin/sulfonylurea combosmonitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects)[metformin/sulfonylurea combos: glipizide/metformin, glyburide/metformin]

methadonemonitor for efficacy, withdrawal: combo may decr. methadone levels, efficacy; precipitate opioid withdrawal symptoms (hepatic metab. induced)

methylphenidatemonitor levels: combo may incr. phenytoin levels, risk of toxicity; methylphenidate may lower seizure threshold (mechanism unknown, hepatic metab. possibly inhibited)[methylphenidate: dexmethylphenidate, methylphenidate, methylphenidate transdermal]

metronidazolemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

miglitolmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

modafinilmonitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects; may decr. armodafinil or modafinil levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)[modafinil: armodafinil, modafinil]

nateglinidemonitor glucose: combo may decr. nateglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

nelfinavirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

nitazoxanidemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

olanzapine/fluoxetinemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

omeprazolemonitor levels, esp. if omeprazole dose >20 mg/day: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)[omeprazole: omeprazole, omeprazole/sodium bicarbonate]

omeprazole/clarithromycin/amoxicillinmonitor phenytoin levels: combo w/ clarithromycin, omeprazole may incr phenytoin levels, risk of toxicity; combo may decr. clarithromycin levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

oxcarbazepinemonitor levels: combo may incr. phenytoin levels, risk of toxicity; decr. oxcarbazepine levels; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. altered; additive effects)

oxycodone/aspirincaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may decr. oxycodone levels, efficacy; incr. risk of CNS depression, psychomotor impairment; combo may incr. phenytoin levels, risk of toxicity (hepatic metab. induced; additive effects; protein binding displacement)

paroxetinemonitor phenytoin levels, monitor paroxetine efficacy: combo may incr. phenytoin levels, risk of toxicity; may decr. paroxetine levels, efficacy (hepatic metab. altered)

phenobarbitalmonitor levels: combo may decr. levels of both drugs (hepatic metab. induced)

phenobarbital/hyoscyamine/atropine/scopolaminemonitor levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

pioglitazonemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

pioglitazone/glimepiridemonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

pioglitazone/metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

primidonemonitor levels: combo may incr. phenobarbital levels, decr. phenytoin levels (hepatic metab. induced; incr. conversion of primidone to phenobarbital)

propoxyphene/acetaminophencaution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy; decr. propoxyphene levels, efficacy, incr. active metabolite formation, risk of toxicity; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced, incr. formation of toxic acetaminophen and propoxyphene metabolites; additive effects)[propoxyphene/acetaminophen: propoxyphene hydrochloride/acetaminophen, propoxyphene napsylate/acetaminophen]

quinidinemonitor levels: combo may decr. quinidine levels, efficacy (hepatic metab. induced)[quinidine: quinidine gluconate, quinidine sulfate]

repaglinidemonitor glucose: combo may decr. repaglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

repaglinide/metforminmonitor glucose: combo may decr. repaglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

rifampinsmonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)[rifampins: rifampin, rifampin/isoniazid, rifampin/isoniazid/pyrazinamide]

rifapentinemonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

ritonavirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

rosiglitazonemonitor glucose: combo may decr. rosiglitazone levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

rosiglitazone/glimepiridemonitor glucose: combo may decr. rosiglitazone levels; may decr. hypoglycemic agent efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

rosiglitazone/metforminmonitor glucose: combo may decr. rosiglitazone levels; may decr. hypoglycemic agent

efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

rufinamidemonitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects; decr. rufinamide levels, efficacy; incr. risk of CNS depression, psychomotor impairment (mechanism unknown; hepatic metab. induced; additive effects)

salicylates, non-acetylatedcaution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)[salicylates, non-acetylated: bismuth subsalicylate, choline magnesium trisalicylate, magnesium salicylate, salsalate]

saquinavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

saxagliptinmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

saxagliptin/metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

sertralinemonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown, hepatic metab. possibly inhibited)

sevelamergive anticonvulsant 1h before or 3h after, monitor efficacy: combo may decr. anticonvulsant levels, efficacy (absorption possibly decreased)

sitagliptinmonitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects)

sitagliptin/metforminmonitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

sitagliptin/simvastatinmonitor statin efficacy; monitor glucose: combo may decr. statin levels, efficacy; may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (hepatic metab. induced; antagonistic effects)

statins, CYP3A4 substratesmonitor efficacy: combo may decr. statin levels, efficacy (hepatic metab. induced)[statins, CYP3A4 substrates: atorvastatin, ezetimibe/simvastatin, lovastatin, simvastatin]

sucralfategive oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)

sulfonylureasmonitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (hepatic metab. induced; antagonistic effects)[sulfonylureas: chlorpropamide, glimepiride, glipizide, glyburide, glyburide micronized, tolazamide, tolbutamide]

tacrolimusmonitor levels: combo may decr. tacrolimus levels, efficacy (hepatic metab. induced)

telithromycinmonitor phenytoin levels: combo may decr. telithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown)

tesamorelinmonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

theophyllinesmonitor levels: combo may decr. theophylline levels, efficacy (hepatic metab. induced)[theophyllines: aminophylline, theophylline]

thyroid hormonesmonitor thyroid function, adjust thyroid replacement dose if needed: combo may decr. thyroid hormone efficacy (hepatic metab. induced, clearance increased)[thyroid hormones: levothyroxine, liothyronine, liotrix, thyroid (porcine)]

tiagabinecaution advised; decr. tiagabine dose if other tx stopped or decreased: combo may incr. risk of CNS depression, psychomotor impairment; tiagabine dosing based on concomitant hepatic enzyme inducing drugs, levels may incr. >2x when induction removed (hepatic metab. induced, clearance incr. 60%; additive effects)

ticlopidinemonitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

tinidazolemonitor levels, efficacy: combo may incr. phenytoin levels, risk of toxicity; decr. tinidazole levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

tipranavircaution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

TNF blocking agentsmonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. altered; TNF blockers may inhibit inflammatory cytokine-induced downregulation of CYP450 enzymes resulting in relative induction of enzymes upon tx start and downregulation upon D/C)[TNF blocking agents: adalimumab, certolizumab pegol, etanercept, golimumab, infliximab]

tocilizumabmonitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. altered; tocilizumab may inhibit inflammatory cytokine-induced downregulation of CYP450 enzymes resulting in relative induction of enzymes upon tx start and downregulation upon D/C)

topiramatemonitor levels: combo may incr. phenytoin levels, risk of toxicity; decr. topiramate levels, efficacy (hepatic metab. altered)[topiramate: phentermine hydrochloride/topiramate, topiramate]

trazodonecaution advised, monitor phenytoin levels: combo may decr. trazodone levels, efficacy; may incr. phenytoin levels, risk of toxicity (hepatic metab. induced; mechanism unknown)

trimethoprimmonitor levels, CBC: combo may incr. phenytoin levels, risk of toxicity, risk of megaloblastic anemia (hepatic metab. inhibited, additive/synergistic folate antagonism)

trimethoprim/sulfamethoxazolemonitor levels, CBC: combo w/ trimethoprim may incr. phenytoin levels, risk of toxicity, risk of megaloblastic anemia (hepatic metab. inhibited, additive/synergistic folate antagonism)

ustekinumabmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. possibly altered; ustekinumab may normalize hepatic enzyme formation suppressed by incr. cytokine levels)

valacyclovirmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown)

valproic acid derivativesmonitor levels; caution advised: combo may decr. valproic acid levels, efficacy; may incr. phenytoin levels, risk of toxicity; may incr. risk of CNS depression, psychomotor

impairment (hepatic metab. altered; additive effects)[valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid]

vigabatrinmonitor phenytoin levels: combo may decr. phenytoin levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

voriconazoleincr. voriconazole dose per pkg insert; monitor phenytoin levels: combo may decr. antifungal levels, efficacy; incr. phenytoin levels, risk of toxicity (hepatic metab. induced; hepatic metab. inhibited)

warfarinmonitor INR: combo may decr. INR, warfarin efficacy and transiently incr. INR, risk of bleeding (hepatic metab. induced, protein binding displacement)

zafirlukastmonitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

Caution Advised

abiraterone acetatecaution advised: combo may decr. abiraterone levels, efficacy (hepatic metab. induced)

aldesleukincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

alendronate/cholecalciferolcaution advised: combo may decr. cholecalciferol efficacy (hepatic metab. induced)

alfentanilcaution advised: combo may decr. alfentanil efficacy (hepatic metab. induced)

apomorphinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive/synergistic effects)

artemether/lumefantrinecaution advised: combo may decr. artemether/lumefantrine levels, efficacy (hepatic metab. induced)

azelastine nasalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal]

belataceptcaution advised: combo may decr. phenytoin levels, efficacy (hepatic metab. possibly

altered; belatacept may normalize hepatic enzyme formation suppressed by incr. cytokine levels)

benzocainecontraindicated if <1 yo, otherwise caution advised: combo w/ benzocaine may incr. risk of methemoglobinemia (additive effects)[benzocaine: benzalkonium chloride/benzocaine/zinc chloride oropharyngeal, benzethonium chloride/benzocaine topical, benzocaine oropharyngeal, benzocaine topical, benzocaine/allantoin/dimethicone/petrolatum topical, benzocaine/butamben/tetracaine topical, benzocaine/camphor/allantoin/dimethicone/petrolatum topical, benzocaine/camphor/allantoin/petrolatum topical, benzocaine/camphor/menthol/allantoin/dimethicone/petrolatum topical, benzocaine/glycerin oropharyngeal, benzocaine/menthol oropharyngeal, benzocaine/menthol topical, benzocaine/pectin oropharyngeal, benzocaine/petrolatum topical, benzocaine/zinc chloride oropharyngeal]

benzocaine/dextromethorphan comboscontraindicated if <1 yo, otherwise caution advised: combo w/ benzocaine may incr. risk of methemoglobinemia (additive effects)[benzocaine/dextromethorphan combos: benzocaine/dextromethorphan oropharyngeal, benzocaine/menthol/dextromethorphan oropharyngeal]

benzodiazepines, CYP3A4 substratescaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)[benzodiazepines, CYP3A4 substrates: alprazolam, midazolam, triazolam]

benzodiazepines, othercaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[benzodiazepines, other: clobazam, estazolam, lorazepam, oxazepam, temazepam]

black cohoshcaution advised: combo may incr. risk of hepatotoxicity (additive toxicity)[black cohosh: Actaea racemosa, baneberry, black cohosh (Actaea racemosa), black snakeroot, bugbane, bugwort, Cimicifuga racemosa, macrotys, rattle root, rattlesnake root, rattletop, rattleweed, squawroot]

bromocriptinecaution advised: combo may decr. bromocriptine levels, efficacy (hepatic metab. induced)

budesonidecaution advised: combo may decr. budesonide levels, efficacy (hepatic metab. induced)

buprenorphinecaution advised: combo may decr. buprenorphine levels, efficacy (hepatic metab.

induced)[buprenorphine: buprenorphine, buprenorphine transdermal, buprenorphine/naloxone]

bupropioncaution advised: combo may decr. buproprion efficacy (hepatic metab. induced)[bupropion: bupropion hydrobromide, bupropion hydrochloride]

buspironecaution advised: combo may decr. buspirone levels, efficacy (hepatic metab. induced)

busulfancaution advised: combo may decr. busulfan levels, efficacy (hepatic metab. induced)

caffeinecaution advised: combo may decr. caffeine levels, efficacy (hepatic metab. induced)[caffeine: caffeine, caffeine citrate, caffeine/sodium benzoate]

carbidopa/levodopacaution advised: combo may decr. levodopa efficacy (mechanism unknown)

carbidopa/levodopa/entacaponecaution advised: combo may decr. levodopa efficacy (mechanism unknown)

carbonic anhydrase inhibitors, systemiccaution advised: combo may incr. risk of osteomalacia (calcium renal excretion increased, metabolic acidosis)[carbonic anhydrase inhibitors, systemic: acetazolamide, methazolamide]

chlordiazepoxidecaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

clonazepamcaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

clorazepatecaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

colchicinecaution advised: combo may decr. colchicine levels, efficacy (hepatic metab. induced)

conivaptancaution advised: combo may decr. conivaptan levels, efficacy (hepatic metab. induced)

corticosteroids, systemiccaution advised: combo may decr. corticosteroid levels, efficacy (hepatic metab. induced)[corticosteroids, systemic: betamethasone sodium phosphate/betamethasone acetate, cortisone, dexamethasone, dexamethasone sodium phosphate, hydrocortisone,

hydrocortisone sodium succinate, methylprednisolone, methylprednisolone acetate, methylprednisolone sodium succinate, prednisolone, prednisone, triamcinolone acetonide]

cyclophosphamidecaution advised: combo may incr. cyclophosphamide active metabolite levels, risk of toxicity (hepatic metab. induced, incr. active metabolite formation)

dantrolenecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

dapsonecaution advised: combo may decr. dapsone levels, efficacy (hepatic metab. induced)

darifenacincaution advised: combo may decr. darifenacin levels, efficacy (hepatic metab. induced)

dasatinibcaution advised: combo may decr. dasatinib levels, efficacy (hepatic metab. induced)

diazoxidecaution advised: combo may incr. risk of hyperglycemia; combo w/ PO diazoxide may decr. phenytoin levels, incr. risk of seizures (additive effects; mechanism unknown)

diclofenaccaution advised: combo may decr. diclofenac levels, efficacy (hepatic metab. induced)[diclofenac: diclofenac potassium, diclofenac sodium, diclofenac/misoprostol]

docetaxelcaution advised: combo may decr. docetaxel levels, efficacy (hepatic metab. induced)

donepezilcaution advised: combo may decr. donepezil levels, efficacy (hepatic metab. induced)

doxercalciferolcaution advised: combo may decr. doxercalciferol efficacy (hepatic metab. induced)

doxycyclinecaution advised, monitor efficacy: combo may decr. doxycycline levels, efficacy (mechanism unknown)

eplerenonecaution advised: combo may decr. eplerenone levels, efficacy (hepatic metab. induced)

ergotamine/caffeinecaution advised: combo may decr. caffeine levels, efficacy (hepatic metab. induced)

eszopiclonecaution advised: combo may decr. eszopiclone levels, efficacy (hepatic metab. induced)

ethanolcaution advised: combo may incr. risk of CNS depression, alter phenytoin levels, incr. risk of seizures (additive effects, hepatic metab. induced w/ chronic and inhibited w/ acute alcohol use; alcohol withdrawal or excessive use may lower seizure threshold)

fentanylcaution advised: combo may decr. fentanyl levels, efficacy (hepatic metab. induced)[fentanyl: fentanyl, fentanyl nasal, fentanyl transdermal, fentanyl transmucosal]

flurazepamcaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

gabapentincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[gabapentin: gabapentin, gabapentin enacarbil]

green teacaution advised: combo may reduce effects of caffeine in green tea (hepatic metab. induced)[green tea: Camellia sinensis, Camellia thea, Chinese tea, green tea (Camellia sinensis), green tea extract, GTE, Japanese tea, Matsu-cha tea, Theaceae, theifers]

haloperidolcaution advised: combo may decr. haloperidol levels, efficacy (mechanism unknown)[haloperidol: haloperidol, haloperidol decanoate, haloperidol lactate]

HRT, estrogencaution advised: combo may result in loss of seizure control; combo may decr. estrogen levels, efficacy (estrogen-induced fluid retention; hepatic metab. induced)[HRT, estrogen: estradiol, estradiol acetate, estradiol cypionate, estradiol transdermal, estradiol vaginal, estradiol valerate, estrogens, conjugated, estrogens, conjugated (synthetic), estrogens, conjugated B (synthetic), estrogens, conjugated vaginal, estrogens, esterified, estrogens, esterified/methyltestosterone, estropipate]

HRT, estrogen/progestin combocaution advised: combo may result in loss of seizure control; combo may decr. estrogen, progestin levels, effica (estrogen-induced fluid retention; hepatic metab. induced)[HRT, estrogen/progestin combo: drospirenone/estradiol, estradiol/levonorgestrel transdermal, estradiol/norethindrone acetate, estradiol/norethindrone acetate transdermal, estradiol/norgestimate, estrogens, conjugated/medroxyprogesterone, norethindrone acetate/ethinyl estradiol]

HRT, progestincaution advised: combo may decr. progestin levels, efficacy (hepatic metab. induced)[HRT, progestin: medroxyprogesterone, norethindrone acetate]

hydromorphonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

hydroxyprogesterone (hormone replacement)caution advised: combo may decr. hydroxyprogesterone levels, efficacy (hepatic metab. induced)[hydroxyprogesterone (hormone replacement): hydroxyprogesterone]

ifosfamidecaution advised: combo may incr. ifosfamide active metabolite and toxic metabolite levels, incr. efficacy and risk of neurotoxicity (hepatic metab. induced, incr. active metabolite and toxic metabolite formation)

isotretinoincaution advised: combo may incr. risk of bone loss (additive effects)

kavacaution advised: combo may incr. risk of hepatotoxicity (additive toxicity)[kava: ava pepper, awa, intoxicating pepper, kao, kava (Piper methysticum), kawa, kew, Piper methysticum, sakau, tonga, yagona]

ketaminecaution advised: combo may decr. ketamine levels, efficacy (hepatic metab. induced)

levocetirizinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

levonorgestrel intrauterine devicecaution advised: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced)

lidocaine topicalcontraindicated if <1 yo, otherwise caution advised: combo w/ topical lidocaine may incr. risk of methemoglobinemia (additive effects)[lidocaine topical: benzethonium chloride/lidocaine topical, hydrocortisone/lidocaine topical, lidocaine oronasopharyngeal, lidocaine topical, lidocaine urethral, lidocaine/epinephrine iontophoretic topical, lidocaine/prilocaine topical, lidocaine/tetracaine topical]

linezolidcaution advised: combo may decr. linezolid levels, efficacy (mechanism unknown, hepatic metab. possibly induced)

meperidinecaution advised: combo may decr. meperidine levels, analgesic efficacy, may incr. risk of normeperidine neurotoxicity (hepatic metab. induced, incr. toxic metabolite formation)

meprobamatecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

mirtazapinecaution advised: combo may decr. mirtazepine levels, effects (hepatic metab. induced)

mitotanecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

montelukastcaution advised: combo may decr. montelukast levels, efficacy (hepatic metab. induced)

morphine liposomalcaution advised: combo may incr. risk of CNS depression, profound sedation, hypotension, other adverse effects (additive effects)

nafarelin nasalcaution advised: combo may incr. risk of bone loss (additive effects)

nevirapinecaution advised: combo may decr. nevirapine levels, efficacy (hepatic metab. induced)

niacin/lovastatincaution advised: combo may decr. lovastatin levels, efficacy (hepatic metab. induced)

niacin/simvastatincaution advised: combo may decr. simvastatin levels, efficacy (hepatic metab. induced)

nitrites/sodium thiosulfatecaution advised: combo w/ nitrites may incr. risk of methemoglobinemia (additive effects)[nitrites/sodium thiosulfate: amyl nitrite/sodium nitrite/sodium thiosulfate, sodium nitrite/sodium thiosulfate]

nitroprussidecaution advised: combo may incr. risk of methemoglobinemia (additive effects)

olopatadine nasalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

oxycodonecaution advised, consider dose adjustment: combo may decr. oxycodone levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

oxycodone/ibuprofencaution advised, consider dose adjustment: combo may decr. oxycodone levels, efficacy;

incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

paclitaxelcaution advised: combo may decr. paclitaxel levels, efficacy (hepatic metab. induced)[paclitaxel: paclitaxel, paclitaxel nanoparticle albumin-bound]

peginterferon alfa 2bcaution advised: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

pimozidecaution advised: combo may decr. pimozide levels, efficacy; combo may incr. risk of CNS depression, psychomotor impairment; pimozide may lower seizure threshold (hepatic metab. induced; additive effects; antagonistic effects)

pramipexolecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

pregabalincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

progesterone (hormone replacement)caution advised: combo may decr. progesterone levels, efficacy (hepatic metab. induced)[progesterone (hormone replacement): progesterone micronized]

progesterone vaginal (hormone replacement)caution advised: combo may decr. progesterone levels, efficacy (hepatic metab. induced)[progesterone vaginal (hormone replacement): progesterone vaginal]

propofolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment; may decr. propofol levels, efficacy (additive effects; hepatic metab. induced)[propofol: fospropofol, propofol]

propoxyphenecaution advised: combo may decr. propoxyphene levels, efficacy, incr. active metabolite formation, risk of toxicity (hepatic metab. induced)[propoxyphene: propoxyphene hydrochloride, propoxyphene napsylate]

quetiapinecaution advised: combo may decr. quetiapine levels, efficacy (clearance increased)

quinine sulfatecaution advised: combo may decr. quinine levels, efficacy (hepatic metab. induced)

ramelteoncaution advised: combo may decr. ramelteon levels, efficacy (hepatic metab. induced)

risperidonecaution advised: combo may decr. risperidone levels, efficacy (hepatic metab. induced)

romidepsincaution advised: combo may decr. romidepsin levels, efficacy (hepatic metab. induced)

ropinirolecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

rotigotine transdermalcaution advised: combo may incr. phenytoin levels, risk of toxicity; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. inhibited; additive effects)

ruxolitinibcaution advised: combo may decr. ruxolitinib levels, efficacy, may incr. active metabolite formation, risk of adverse effects (hepatic metab. induced)

selegilinecaution advised: combo may decr. selegiline levels, efficacy (hepatic metab. induced)

selegiline transdermalcaution advised: combo may decr. selegiline levels, efficacy (hepatic metab. induced)

sildenafilcaution advised: combo may decr. sildenafil levels, efficacy (hepatic metab. induced)

sodium oxybatecaution advised: combo may incr. risk of CNS depression, other adverse effects (additive effects)

solifenacincaution advised: combo may decr. solifenacin levels, efficacy (hepatic metab. induced)

sorafenibcaution advised, monitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects; decr. sorafenib levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

streptozocincaution advised: combo may decr. streptozocin efficacy (mechanism unknown)

sufentanilcaution advised: combo may decr. sufentanil efficacy (hepatic metab. induced)

tamoxifencaution advised: combo may decr. tamoxifen and active metabolite levels, efficacy (hepatic metab. induced)

tapentadolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

teniposidecaution advised: combo may decr. teniposide levels, efficacy (hepatic metab. induced)

tetrabenazinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

thiotepacaution advised: combo may decr. thiotepa levels, efficacy; may incr. thiotepa active metabolite levels, risk of toxicity (hepatic metab. induced)

toremifenecaution advised: combo may decr. toremifene levels, efficacy (hepatic metab. induced)

tricyclic antidepressantscaution advised: combo w/ TCAs may alter seizure control; combo may incr. risk of CNS depression, psychomotor impairment (decreased seizure threshold; additive effects)[tricyclic antidepressants: amitriptyline, amoxapine, chlordiazepoxide/amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, perphenazine/amitriptyline, protriptyline, trimipramine]

vemurafenibcaution advised: combo may decr. vemurafenib levels, efficacy (hepatic metab. induced)

vinca alkaloidscaution advised: combo may decr. vinca alkaloid levels, efficacy (hepatic metab. induced)[vinca alkaloids: vinblastine, vincristine, vinorelbine]

zaleploncaution advised: combo may decr. zaleplon levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

zolpidemcaution advised: combo may decr. zolpidem levels, efficacy (hepatic metab. induced)

zonisamidecaution advised: combo may decr. zonisamide levels, efficacy (hepatic metab. induced)

Adverse Reactions

Serious Reactions

ventricular fibrillation (IV use) hypotension, severe (IV use)

cardiovascular collapse (IV use)

AV conduction abnormalities (IV use)

hepatotoxicity

thrombocytopenia

leukopenia

agranulocytosis

pancytopenia

anemia, megaloblastic

exfoliative dermatitis

Stevens-Johnson syndrome

toxic epidermal necrolysis

rash w/ eosinophilia and systemic sx

tissue necrosis (IV use)

purple glove syndrome (IV use)

anaphylaxis

lymphoma

lupus erythematosus

osteomalacia

toxic delirium

suicidality

periarteritis nodosa

Common Reactions

nausea vomiting

rash

nystagmus

ataxia

slurred speech

dizziness

confusion

paresthesia

blurred vision

somnolence

constipation

headache

insomnia

gingival hyperplasia

taste changes

tremor

lymphadenopathy

coarse facies

hyperglycemia

osteomalacia

phlebitis (IV use)

Peyronie dz

Safety/Monitoring

Pregnancy: D (Positive evidence of human fetal risk; maternal benefit may outweigh fetal risk in serious or life-threatening situations; see pkg insert for drug-specific recs)

Lactation: Probably Safe (Limited information in animals and/or humans demonstrates no risk/minimal risk of adverse effects to infant/breast milk production; caution advised)

Therapeutic Drug Levels 10-20 mcg/mL (total), 1-2 mcg/mL (free); Toxic Levels: >20 mcg/mL (total), >2 mcg/mL (free); Timing: 2-4h after IV load, 24h after PO load, or just prior to next dose; Time to Steady State: 7-10 days, highly variable; Info: status epilepticus may require higher level

Monitoring Parameters Cr at baseline; CBC; folate; LFTs; serum drug levels periodically and if change dosage

form/brand; BP, ECG, resp. fxn continuously during and x20min after IV load; dental exam q3mo; s/sx depression, behavior changes, suicidality

Look/Sound-Alike Drug Names [from www.usp.org]

phenytoin confused with: phenylephrine

phenytoin sodium confused with: Feldene; fluconazole; fosphenytoin; nystatin; phenazopyridine; phenobarbital; phytonadione

Pharmacology

Metabolism: liver; CYP450: 2C9 (primary), 2C19 substrate; 2B6, 2C9/19, 3A4 inducer

Excretion: bile, urine; Half-life: 22h

Subclass: Seizure Disorders

Mechanism of Actionmodulates neuronal voltage-dependent sodium and calcium channels

Manufacturer/Pricing

Manufacturer: generic

DEA/FDA: Rx: (Requires prescription; not a controlled substance)

Approximate Retail Price

from  www.drugstore.com

capsule:

100 mg (90 ea): $31.99

suspension:

125 mg/5ml (237 ml): $28.98

Patient Education

Nombre Genérico: phenytoin (oral)

Nombres de las Marcas: Dilantin, Dilantin Infatabs, Dilantin-125, Phenytek

¿Cuál es la información más importante que debo saber sobre phenytoin?

Usted no debe tomar phenytoin si usted también está tomando delavirdine (Rescriptor), o si es alérgico a phenytoin, ethotoin (Peganone), fosphenytoin (Cerebyx), o mephenytoin (Mesantoin).

Si usted está embarazada, NO EMPIECE A TOMAR phenytoin salvo que su médico le haya indicado hacerlo. Phenytoin puede hacer daño al bebé nonato, pero tener una convulsión cuando está embarazada le puede hacer daño a la madre y al bebé. Si usted queda embarazada mientras está tomando phenytoin, NO DEJE DE TOMAR la medicina sin el consejo de su médico. Control de las convulsiones es muy importante durante el embarazo y el beneficio de evitar convulsiones puede sobrepasar el riesgo que presenta tomar phenytoin.

Usted puede tener pensamientos de suicidio cuando empiece a tomar esta medicina. Su médico necesitará examinarlo con regularidad. No falte a las visitas médica establecidas por su médico.

Informe a su médico de algún síntoma nuevo o que empeora, como: cambios del humor o del comportamiento, depresión, ansiedad, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o de físico), o tiene pensamientos de suicidio o de querer hacerse daño.

¿Qué es phenytoin?

Phenytoin es una droga antiepiléptica, también conocida como un anticonvulsivante. Funciona reduciendo los impulsos en el cerebro que causan convulsiones.

Phenytoin se usa para el control de las convulsiones. Phenytoin no trata todas los tipos de convulsiones, y su médico determinará si es la medicina correcta para usted.

Phenytoin puede también usarse para fines no mencionados en esta guía del medicamento.

¿Qué debería discutir con el profesional del cuidado de la salud antes de usar phenytoin?

Usted no debe tomar phenytoin si usted también está tomando delavirdine (Rescriptor), o si es alérgico a phenytoin, ethotoin (Peganone), fosphenytoin (Cerebyx), o mephenytoin (Mesantoin).

Para asegurarse que usted puede tomar phenytoin de forma segura, dígale a su médico si usted tiene cualquiera de estas otras condiciones:

enfermedad del hígado; lupus;

diabetes;

deficiencia de la vitamina D o cualquier otra condición que desgasta los huesos;

porfiria (un trastorno genético de enzima que causa síntomas que afectan la piel o el sistema nervioso); o

si usted consume gran cantidad de alcohol.

Usted puede tener pensamientos de suicidio mientras toma este medicamento. Dígale a su médico si usted tiene síntomas de la depresión o pensamientos de suicidio nuevos o que empeoran durante los primeros meses del tratamiento, o cuando tenga cambios en su dosis.

Su familia o quienes lo atiendan también deben mantenerse alertas a los cambios en su humor o síntomas. Su médico necesitará examinarlo con regularidad. No falte a las visitas médicas establecidas por su médico.

Los pacientes con antepasados de origen Asiático pueden tener un riesgo más alto de desarrollar una reacción a la piel, rara, pero de gravedad con phenytoin. Su médico puede recomendar pruebas de la sangre antes de que empiece la medicina para determinar su riesgo a tener esta reacción.

Categoría D del embarazo por la FDA. Phenytoin le puede hacer daño al bebé nonato, pero tener una convulsión cuando está embarazada le puede hacer daño a la madre y al bebé.

Si usted está embarazada, NO EMPIECE A TOMAR phenytoin salvo que su médico le haya indicado. Si usted queda embarazada mientras está tomando phenytoin, NO DEJE DE TOMAR la medicina sin el consejo de su médico.

El control de las convulsiones es muy importante durante el embarazo. El beneficio de evitar convulsiones puede sobrepasar el riesgo que presenta tomar phenytoin. Siga las instrucciones de su médico acerca de tomar phenytoin durante su embarazo.

Phenytoin puede hacer las pastillas anticonceptivas menos efectivas. Para prevenir el embarazo mientras toma phenytoin, use un método de control de natalidad no hormonal (como el condón o diafragma con espermicida).

Phenytoin puede pasar a la leche materna y causarle daño al bebé lactante. Usted no debe amamantar mientras está usando phenytoin.

¿Cómo debo tomar phenytoin?

Tómelo exactamente cómo lo haya recetado su médico. No lo tome en cantidades mayores o menores, o por más tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripción.

No triture, mastique, rompa, o abra una cápsula de liberación extendida. Tráguelas enteras. Romper o abrir la píldora puede causar que mucha medicina pase al cuerpo de inmediato. No use ninguna cápsula que ha cambiado de color. Llame a su médico para una nueva prescripción.

Agite bien la suspensión oral (líquida) antes de medir una dosis. Mida el líquido con una cucharita o taza de medición, no lo haga con una cuchara normal. Si no tiene con que medir su dosis, pídale una a su farmacéutico.

Para estar seguro de que este medicamento está ayudando su condición, tal vez se necesite examinar su sangre con frecuencia. También puede ser que necesite exámenes de sangre cuando cambie de una presentación de phenytoin a otra. Visite a su médico con regularidad.

Si está tomando phenytoin para el tratamiento de convulsiones, siga tomando la medicina aunque se sienta bien. Usted puede tener un aumento en convulsiones si deja de tomar phenytoin. No cambie su dosis de phenytoin sin la previa aprobación de su médico. Dígale a su médico si le parece que su medicina ha dejado de funcionar como lo hacia para el tratamiento de su condición.

Lleve con usted una tarjeta de identificación que indique que usted está tomando phenytoin. Cualquier proveedor del cuidado médico que lo trate debería saber que usted esta usando una medicina para el control de convulsiones.

Guarde a temperatura ambiente lejos de la humedad, luz, y calor.

¿Qué sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sáltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome más medicina para alcanzar la dosis pasada.

¿Qué sucedería en una sobredosis?

Busque atención médica de emergencia o llame a la línea de Poison Help al 1-800-222-1222. La sobredosis de phenytoin puede ser fatal. Los síntomas de sobredosis pueden incluir movimientos espasmódicos de los ojos, arrastre de las palabras al hablar, perdida del balance,

temblores, rigidez muscular o debilidad, náusea, vómito, sentir que se puede desmayar, desmayo, y respiración lenta o no profunda.

¿Qué debo evitar mientras uso phenytoin?

Evite beber alcohol mientras esté tomando phenytoin. Consumir alcohol puede aumentar sus niveles de phenytoin en la sangre y puede aumentar los efectos secundarios. Consumir alcohol diariamente puede disminuir sus niveles de phenytoin en la sangre, lo que puede aumentar su riesgo de convulsiones.

Evite tomar antiácidos al mismo tiempo que toma phenytoin. Los antiácidos pueden hacer más difícil para que su cuerpo pueda absorber la medicina.

Phenytoin puede perjudicar su pensamiento o reacciones. Tenga cuidado si usted conduce un vehículo o tenga que hacer algo que demande se mantenga alerta.

¿Cuáles son los efectos secundarios posibles de phenytoin?

Busque atención médica de emergencia si usted tiene alguno de estos síntomas de una reacción alérgica: ronchas; dificultad para respirar; hinchazón de su cara, labios, lengua, o garganta. Es más probable que tenga una reacción alérgica si es de raza Americana-Africana.

Informe a su médico de algún síntoma nuevo o que empeora, como: cambios del humor o del comportamiento, depresión, ansiedad, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o de físico), o tiene pensamientos de suicidio o de querer hacerse daño.

Llame a su médico de inmediato si usted tiene un efecto secundario grave como:

fiebre, glándulas hinchadas, dolor de cuerpo, síntomas de la gripe; sarpullido, moretones o sangrado fácil, hormigueo severo, entumecimiento, dolor,

debilidad muscular;

dolor en la parte superior del estómago, pérdida del apetito, orina oscura, ictericia (color amarillo de la piel u ojos);

dolor de pecho, ritmo cardíaco irregular, sensación de que le falta aire al respirar;

confusión, náusea y vómito, hinchazón, ganancia de peso rápida, orinar menos de lo usual o nada en absoluto;

tos nueva o que empeora con fiebre, dificultad para respirar;

temblor (sacudidas que no puede controlar), movimientos musculares inquietos en sus ojos, lengua, quijada, o cuello;

color de piel con parches, manchas rojas, o un sarpullido en forma de mariposa sobre sus mejillas y nariz (que empeora con la luz del sol); o

reacción severa de la piel -- fiebre, dolor de garganta, hinchazón en su cara o lengua, quemazón en sus ojos, dolor de la piel, seguido por un sarpullido rojo o púrpura que se extiende (especialmente en la cara o la parte superior del cuerpo) y causa ampollas y descamación.

Efectos secundarios de menor gravedad pueden incluir:

habla arrastrado, perdida del balance o coordinación; encías hinchadas o adoloridas; o

dolor de cabeza, nerviosismo, o problemas para dormir (insomnio).

Esta lista no menciona todos los efectos secundarios y puede ser que ocurran otros. Llame a su médico para consejos médicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

¿Qué otras drogas afectarán a phenytoin?

Varias drogas pueden tener interacciones con phenytoin. La lista que se presenta abajo no incluye todas las drogas. Dígale a su médico si usted está usando:

antibióticos como cycloserine (Seromycin), doxycycline (Doryx, Vibramycin, Adoxa), isoniazid (para tratar tuberculosis), linezolid (Zyvox), rifampin (Rimactane, Rifadin, Rifamate), o sulfas (Bactrim, Septra, Sulfatrim, SMX-TMP, y otras);

un antidepresivo (como Elavil, Vanatrip, Limbitrol, Sinequan, Silenor, Pamelor, Paxil, Zoloft, Desyrel, y otras);

aspirin u otros salicilatos;

pastillas para el control de la natalidad o terapia de reemplazo hormonal;

un anticoagulante como warfarin (Coumadin, Jantoven);

ciertos sedantes (Librium, Librax, Limbitrol, Valium) o antidepresivos (Desyrel, Luvox, Zoloft, Prozac, Rapiflux, Sarafem, Selfemra, Symbyax);

medicamento para el corazón como amiodarone (Cordarone, Pacerone), digoxin (digitalis, Lanoxin), furosemide (Lasix), o quinidine (Quin-G);

prochlorperazine (Compazine, Compro), promethazine (Pentazine, Phenergan, Anergan, Antinaus), y otras fenotiazinas;

esteroides (prednisone y otras);

medicamento para convulsiones (como Carbatrol, Equetro, Tegretol, Solfoton, Depakene, o Depakote);

medicinas para reducir el ácido del estómago (como Tagamet, Prilosec, Zegerid, Zantac, Pepcid, o Axid; o

theophylline (Elixophyllin, Theo-Dur, Theo-Bid, Theolair, Uniphyl).

Esta lista no incluye todas las drogas y hay muchas otras drogas que pueden tener interacciones con phenytoin. Dígale a su médico acerca de todas los medicamentos que usted usa. Incluya los productos que se obtienen con o sin receta, vitaminas, y productos herbarios. No empiece un nuevo medicamento sin primero decirle a su médico. Mantenga una lista de todas sus medicinas y muéstresela a cualquier profesional de la salud que lo atienda.

¿Dónde puedo obtener más información?

Su farmacéutico le puede dar más información acerca de phenytoin.

Drug

lidocainegeneric

Entire Monograph

Adult Dosing

Dosage forms:  SC; IM; IV; INJ

ventricular arrhythmias

[1-4 mg/min IV]Start: 1-1.5 mg/kg IV q3-5min, may repeat bolus until effect; Max: 300 mg total bolus in 1h

ACLS, VF/pulseless VT

[0.5-0.75 mg/kg IV/IO q5-10min prn]Start: 1-1.5 mg/kg IV/IO x1; Max: 3 mg/kg total; Info: see ACLS tables

*status epilepticus

[1 mg/kg IV bolus]Info: may give 0.5 mg/kg 2min after 1st dose, infusion 30 mcg/kg/min

local anesthesia

[dosing varies]Max: 300 mg total

renal dosing

[no adjustment]severe renal dz: incr. risk of CNS toxicity from accumulation of active metabolites

hepatic dosing

[not defined]

severe hepatic dz: incr. risk toxic lidocaine levels

Peds Dosing

Dosage forms:  IV; INJ

ventricular arrhythmias

[20-50 mcg/kg/min IV]Start: 1 mg/kg slow IV, may repeat q10-15min x2, up to 3-5 mg/kg in 1st hour; Max: 20 mcg/kg/min if in shock or CHF; Alt: 1-2.5 mg/kg ET load; Info: may bolus via intraosseous route

PALS, VF/pulseless VT

[1 mg/kg IV/IO prn]Max: 100 mg/dose; Alt: 2-3 mg ETT prn; Info: see PALS tables

renal dosing

[no adjustment]severe renal dz: incr. risk of CNS toxicity from accumulation of active metabolites

hepatic dosing

[not defined]severe hepatic dz: incr. risk toxic lidocaine levels

Contraindications/Cautions

hypersens. to drug/class/compon. Adams-Stokes syndrome

WPW syndrome

heart block w/o pacemaker

intra-articular continuous infusion

caution if impaired cardiac fxn

caution if heart block

caution if CHF

caution if bradycardia

caution if marked hypoxia

caution if respiratory depression, severe

caution if hypovolemia

caution if shock

caution if hepatic impairment

caution if renal impairment

caution in elderly pts

Drug Interactions

Contraindicated

dronedaronecontraindicated: combo may incr. lidocaine levels, risk of adverse effects, including QT prolongation, cardiac arrhythmias (hepatic metab. inhibited, additive prolonged QT)

morphine liposomalcontraindicated w/in 48h of morphine liposomal use for epidural local anesthetics except bupivacaine; give bupivacaine >30min before morphine liposomal: combo may decr. efficacy, incr. risk of adverse effects; bupivacaine may incr. peak morphine serum levels (potential incompatibility in epidural space; mechanism unknown)

Avoid/Use Alternative

acetaminophen/aspirinavoid combo or use alternative: combo of local anesthetics and acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/aspirin/caffeineavoid combo or use alternative: combo of local anesthetics and acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/caffeineavoid combo or use alternative: combo of local anesthetics and acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/caffeine/CNS depressant combosavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia; combo may incr. opioid analgesic effects, CNS and respiratory depression, other adverse effects (additive/synergistic effects)[acetaminophen/caffeine/CNS depressant combos: acetaminophen/caffeine/dihydrocodeine, butalbital/acetaminophen/caffeine, butalbital/acetaminophen/caffeine/codeine]

acetaminophen/chlorpheniramineavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/chlorpheniramine/dextromethorphanavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/chlorpheniramine/dextromethorphan/phenylephrineavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/chlorpheniramine/phenylephrineavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/dextromethorphanavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/dextromethorphan/phenylephrineavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)[acetaminophen/dextromethorphan/phenylephrine: acetaminophen/dextromethorphan/phenylephrine, acetaminophen/dextromethorphan/phenylephrine/guaifenesin]

acetaminophen/dextromethorphan/pseudoephedrineavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)[acetaminophen/dextromethorphan/pseudoephedrine: acetaminophen/dextromethorphan/pseudoephedrine/guaifenesin]

acetaminophen/diphenhydramineavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/diphenhydramine/dextromethorphanavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/diphenhydramine/phenylephrineavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/doxylamine/dextromethorphanavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/doxylamine/dextromethorphan/phenylephrineavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/doxylamine/dextromethorphan/pseudoephedrineavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/doxylamine/phenylephrineavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/magnesium salicylate/pamabromavoid combo or use alternative: combo of local anesthetics and acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/pamabromavoid combo or use alternative: combo of local anesthetics and acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/pheniramine/phenylephrineavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/phenylephrineavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)[acetaminophen/phenylephrine: acetaminophen/phenylephrine, acetaminophen/phenylephrine/guaifenesin]

acetaminophen/pseudoephedrineavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)[acetaminophen/pseudoephedrine: acetaminophen/pseudoephedrine/guaifenesin]

acetaminophensavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)[acetaminophens: acetaminophen, acetaminophen rectal, acetaminophen/guaifenesin, isometheptene/dichloralphenazone/acetaminophen]

amiodaroneweigh risk/benefit; monitor levels, BP, toxicity: combo may incr. lidocaine levels, risk of adverse effects, including QT prolongation, cardiac arrhythmias (hepatic metab. inhibited; additive effects)

butalbital/acetaminophenavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

chloroquine phosphateavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)

dapsoneavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)

disopyramideweigh risk/benefit: combo may incr. risk of QT prolongation, cardiac arrhythmias (additive effects)

erythromycin/sulfisoxazoleavoid combo or monitor levels w/ systemic lidocaine: combo w/ erythromycin may incr. lidocaine or active metabolite levels, risk of adverse effects; combo w/ sulfonamides may incr. risk of methemoglobinemia (hepatic metab. inhibited; additive effects)

local anesthetics/epinephrineavoid combo or use alternative: combo may incr. risk of methemoglobinemia, other adverse effects (additive effects; duplicate tx)[local anesthetics/epinephrine: articaine/epinephrine]

nitratesavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)[nitrates: isosorbide dinitrate, isosorbide dinitrate/hydralazine, isosorbide mononitrate, nitroglycerin, nitroglycerin intra-anal, nitroglycerin topical, nitroglycerin transdermal]

nitrofurantoinavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)

nitroprussideavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)

opiate/acetaminophen combosavoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia; combo may incr. opioid analgesic effects, CNS and respiratory depression, other adverse effects (additive/synergistic effects)[opiate/acetaminophen combos: acetaminophen/codeine, hydrocodone/acetaminophen, oxycodone/acetaminophen, pentazocine/acetaminophen]

phenobarbitalavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)

phenobarbital/hyoscyamine/atropine/scopolamineavoid combo or use alternative: combo w/ phenobarbital may incr. risk of methemoglobinemia (additive effects)

phenytoinsavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)[phenytoins: fosphenytoin, phenytoin]

primaquineavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)

sodium oxybateavoid combo: combo may incr. risk of CNS and resp. depression, other adverse effects (additive effects)

sulfadiazineavoid combo or use alternative: combo w/ sulfonamides may incr. risk of methemoglobinemia (additive effects)

sulfasalazineavoid combo or use alternative: combo w/ sulfonamides may incr. risk of methemoglobinemia (additive effects)

trimethoprim/sulfamethoxazoleavoid combo or use alternative: combo w/ sulfonamides may incr. risk of methemoglobinemia (additive effects)

Monitor/Modify Tx

azole antifungalsmonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)[azole antifungals: fluconazole, itraconazole, ketoconazole, posaconazole, voriconazole]

boceprevirmonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)

chloramphenicolmonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)

ciprofloxacinmonitor levels w/ systemic lidocaine: combo may incr. lidocaine levels, risk of adverse effects (hepatic metab. inhibited)

clarithromycinsmonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite

levels, risk of adverse effects (hepatic metab. inhibited)[clarithromycins: clarithromycin, lansoprazole/amoxicillin/clarithromycin, omeprazole/clarithromycin/amoxicillin]

cobicistatmonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)[cobicistat: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil]

conivaptanmonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)

cyclosporinemonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)[cyclosporine: cyclosporine modified, cyclosporine non-modified]

delavirdinemonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)

erythromycin basemonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)

erythromycin ethylsuccinatemonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)

erythromycin lactobionatemonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)

erythromycin stearatemonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)

fluvoxaminemonitor levels w/ systemic lidocaine: combo may incr. lidocaine levels, risk of adverse effects (hepatic metab. inhibited)

HIV protease inhibitorsmonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)[HIV protease inhibitors: atazanavir, darunavir, fosamprenavir, indinavir, lopinavir/ritonavir, nelfinavir, ritonavir, saquinavir, tipranavir]

imatinibmonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)

nevirapinemonitor levels: combo may decr. lidocaine levels, efficacy (hepatic metab. induced)

propranololmonitor levels w/ systemic lidocaine: combo may incr. lidocaine levels, risk of adverse effects (clearance decreased)

propranolol/hydrochlorothiazidemonitor levels w/ systemic lidocaine: combo may incr. lidocaine levels, risk of adverse effects (clearance decreased)

sevelamergive antiarrhythmic 1h before or 3h after, monitor efficacy: combo may decr. antiarrhythmic level, efficacy (absorption possibly decreased)

telaprevirmonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)

telithromycinmonitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)

TNF blocking agentsmonitor levels: combo may decr. lidocaine levels, efficacy (hepatic metab. altered; TNF blockers may inhibit inflammatory cytokine-induced downregulation of CYP450 enzymes resulting in relative induction of enzymes upon tx start and downregulation upon D/C)[TNF blocking agents: adalimumab, certolizumab pegol, etanercept, golimumab, infliximab]

tocilizumabmonitor levels: combo may decr. lidocaine levels, efficacy (hepatic metab. altered; tocilizumab may inhibit inflammatory cytokine-induced downregulation of CYP450 enzymes resulting in relative induction of enzymes upon tx start and downregulation upon D/C)

ustekinumabmonitor levels: combo may decr. lidocaine levels, efficacy (hepatic metab. possibly altered; ustekinumab may normalize hepatic enzyme formation suppressed by incr. cytokine levels)

Caution Advised

belataceptcaution advised: combo may decr. lidocaine levels, efficacy (hepatic metab. possibly altered; belatacept may normalize hepatic enzyme formation suppressed by incr. cytokine levels)

chlorpheniramine/hydrocodonecaution advised: combo may incr. hydrocodone analgesic effects, incr. respiratory depression, other side effects (additive/synergistic effects)

cimetidinecaution advised w/ systemic lidocaine: combo may incr. lidocaine levels, risk of adverse effects (mechanism unknown, hepatic metab. possibly inhibited)

clonidinecaution advised w/ epidural clonidine, may use for therapeutic advantage: combo may prolong epidural local anesthetic effects, incl. sensory and motor blockade (additive effects)[clonidine: clonidine, clonidine transdermal]

CNS depressant/aspirin/caffeine comboscaution advised: combo may incr. opioid analgesic effects, incr. respiratory depression, other side effects (additive effects)[CNS depressant/aspirin/caffeine combos: butalbital/aspirin/caffeine, butalbital/aspirin/caffeine/codeine, dihydrocodeine/aspirin/caffeine]

cocaine oronasolaryngealcaution advised, consider cumulative doses/potential systemic exposure from all topical or local anesthetic formulations used concurrently: combo may incr. risk of adverse effects (additive effects)

epinephrinecaution advised, use for therapeutic advantage: combo may prolong anesthesia, and may decr. systemic toxicity and burning w/ injection of local anesthetic (absorption decreased via vasoconstriction)

flecainidecaution advised: combo may incr. risk of cardiac arrhythmias (additive effects)

hydrocodone/chlorpheniramine/pseudoephedrinecaution advised: combo may incr. risk of CNS and resp. depression, profound sedation, hypotension, other adverse effects (additive effects)

hydrocodone/ibuprofencaution advised: combo may incr. risk of resp. depression, other adverse effects (additive effects)

hydrocodone/pseudoephedrinecaution advised, consider lower hydrocodone doses: combo may incr. risk of CNS and resp. depression, profound sedation, hypotension, other adverse effects (additive effects)

inhaled anestheticscaution advised: combo may incr. risk of cardiac arrhythmias (additive effects)[inhaled anesthetics: desflurane, enflurane, isoflurane, sevoflurane]

lidocaine intradermal systemcaution advised, consider cumulative doses/potential systemic exposure from all topical or local anesthetic formulations used concurrently: combo may incr. risk of methemoglobinemia, other adverse effects (additive effects)

methadonecaution advised, consider opioid dose reduction: combo may incr. risk of CNS and resp. depression (additive effects)

neuromuscular blockers, non-depol.caution advised: combo may potentiate neuromuscular blockade (synergistic effects)[neuromuscular blockers, non-depol.: atracurium, cisatracurium, pancuronium, rocuronium, vecuronium]

nitrites/sodium thiosulfatecaution advised: combo w/ nitrites may incr. risk of methemoglobinemia (additive effects)[nitrites/sodium thiosulfate: amyl nitrite/sodium nitrite/sodium thiosulfate, sodium nitrite/sodium thiosulfate]

opiate agonist/antagonistscaution advised: combo may incr. risk of CNS and resp. depression (additive effects)[opiate agonist/antagonists: buprenorphine, buprenorphine transdermal, buprenorphine/naloxone, butorphanol, butorphanol nasal, nalbuphine, pentazocine lactate, pentazocine/naloxone]

opiate/aspirin comboscaution advised: combo may incr. opioid analgesic effects, incr. respiratory depression, other side effects (additive effects)[opiate/aspirin combos: carisoprodol/aspirin/codeine, oxycodone/aspirin]

opiatescaution advised, consider dose reduction: combo may incr. risk of CNS and resp. depression; opioid anesthestics used w/ high levels of epidural or spinal anesthesia may also have incr. risk of hypotension, bradycardia (additive effects)[opiates: alfentanil, codeine phosphate, codeine sulfate, codeine/guaifenesin, fentanyl, fentanyl nasal, fentanyl transdermal, fentanyl transmucosal, hydrocodone/homatropine, hydromorphone, levorphanol, meperidine, morphine sulfate, morphine sulfate/naltrexone, oxycodone, oxymorphone, remifentanil, sufentanil]

oxycodone/ibuprofencaution advised: combo may incr. risk of resp. depression, other adverse effects (additive effects)

promethazine/codeinecaution advised, consider dose reduction: combo may incr. risk of CNS and resp. depression; opioid anesthestics used w/ high levels of epidural or spinal anesthesia may also have incr. risk of hypotension, bradycardia (additive effects)

propafenonecaution advised, if possible withhold antiarrhythmics for 2-3 half-lives before initiating new antiarrhythmic: combo may incr. risk of CNS adverse effects (additive effects)

propoxyphenecaution advised: combo may incr. opioid analgesic effects, incr. respiratory depression, other side effects (additive effects)[propoxyphene: propoxyphene hydrochloride, propoxyphene napsylate]

propoxyphene/acetaminophencaution advised: combo may incr. propoxyphene analgesic effects, incr. respiratory depression, other side effects (additive/synergistic effects)[propoxyphene/acetaminophen: propoxyphene hydrochloride/acetaminophen, propoxyphene napsylate/acetaminophen]

sotalolcaution advised, if possible withhold antiarrhythmics for 2-3 half-lives before initiating new antiarrhythmic: combo may incr. risk of cardiac arrhythmias (additive effects)[sotalol: sotalol, sotalol AF]

succinylcholinecaution advised: combo may potentiate, prolong neuromuscular blockade (mechanism unknown)

topical anestheticscaution advised: combo may incr. risk of adverse effects (additive effects)[topical anesthetics: benzalkonium chloride/benzocaine/zinc chloride oropharyngeal, benzethonium chloride/benzocaine topical, benzethonium chloride/lidocaine topical, benzocaine oropharyngeal, benzocaine topical, benzocaine/allantoin/dimethicone/petrolatum topical, benzocaine/butamben/tetracaine topical, benzocaine/camphor/allantoin/dimethicone/petrolatum topical, benzocaine/camphor/allantoin/petrolatum topical, benzocaine/camphor/menthol/allantoin/dimethicone/petrolatum topical, benzocaine/dextromethorphan oropharyngeal, benzocaine/glycerin oropharyngeal, benzocaine/menthol oropharyngeal, benzocaine/menthol topical, benzocaine/menthol/dextromethorphan oropharyngeal, benzocaine/pectin oropharyngeal, benzocaine/petrolatum topical, benzocaine/zinc chloride oropharyngeal, hydrocortisone/lidocaine topical, lidocaine oronasopharyngeal, lidocaine topical, lidocaine urethral, lidocaine/epinephrine iontophoretic topical, lidocaine/prilocaine topical, lidocaine/tetracaine topical]

Adverse Reactions

Serious Reactions

seizures respiratory arrest

arrhythmias, worsened

status asthmaticus

heart block

bradycardia

coma

anaphylaxis

methemoglobinemia

Common Reactions

injection site pain lightheadedness

tremor

confusion

hypotension

blurred vision

tinnitus

anxiety

dizziness

euphoria

drowsiness

lethargy

nausea

vomiting

agitation

hallucinations

Safety/Monitoring

Pregnancy: B (Animal studies show no risk or adverse fetal effects but controlled human 1st trimester studies not avail/do not confirm; no evidence of 2nd or 3rd trimester risk; fetal harm possible but unlikely; see pkg insert drug-specific recs)

Lactation: Safe (Substantial human data demonstrates no risk/minimal risk to infant/breast milk production or medication not orally bioavailable to infant; medication usually compatible with breastfeeding)

Therapeutic Drug Levels 1.5-5 mcg/mL; Toxic Levels: >6 mcg/mL; Timing: 1-2h after start (efficacy), 24-48h (toxicity); Info: drug accumulates if prolonged use

Monitoring Parameters cardiovascular and respiratory vital signs

Look/Sound-Alike Drug Names [from www.usp.org]

lidocaine confused with: bupivacaine; linezolid

Pharmacology

Metabolism: liver extensively; CYP450: 1A2 (primary), 3A4 substrate; Info: active metabolites

Excretion: urine (10% unchanged); Half-life: 1.5-2h

Subclass: Antiarrhythmics, Parenteral; ACLS/PALS/NALS; Anesthetics, Local

Mechanism of Actioninhibits Na ion channels, stabilizing neuronal cell membranes and inhibiting nerve impulse initiation and conduction (amide local anesthetic); depresses action potential phase 0 (class IB antiarrhythmic)

Manufacturer/Pricing

Manufacturer: generic

DEA/FDA: Rx: (Requires prescription; not a controlled substance)

Approximate Retail Price

from  www.drugstore.com

solution:

1 % (pf) (1 vial, 30 ml): $16.62

solution:

1 % (50 ml): $45.99

Patient Education

Patient education material for this drug is not currently available.

Drug

alprazolamgeneric

Entire Monograph

Adult Dosing

Dosage forms:  0.25,0.5,1,2; 0.25,0.5,1,2 ODT; 0.5,1,2,3 ER; 1/mL

anxiety

[0.25-0.5 mg PO tid]Start: 0.25 mg PO tid, 0.25 mg PO bid-tid if elderly/debilitated; incr. q3-4 days; Max: 4 mg/day; Info: use lowest effective dose, shortest duration tx; slow taper to D/C by max 0.5 mg/day

panic disorder

[immediate-release form]Dose: 0.5-3 mg PO tid; Start: 0.5 mg PO tid, 0.25 mg PO bid-tid if elderly/debilitated; incr. up to 1 mg/day q3-4 days; Info: use lowest effective dose, shortest duration tx; may divide dose more freq. if interdose sx emerge; slow taper to D/C by max 0.5 mg/day q3 days

[extended-release form]Dose: 3-6 mg ER PO qd; Start: 0.5-1 mg ER PO qd, 0.5 mg ER qd if elderly/debilitated; incr. up to 1 mg/day q3-4 days; Info: use lowest effective dose, shortest duration tx; slow taper to D/C by max 0.5 mg/day q3 days; do not cut/crush/chew ER form

renal dosing

[no adjustment]HD: no supplement

hepatic dosing

[adjust dose amount, frequency]advanced hepatic dz: start 0.25 mg PO bid-tid, 0.5 mg ER PO qd; titrate gradually

Peds Dosing

Peds dosing is currently unavailable or not applicable for this drug.

Contraindications/Cautions

hypersens. to drug/class/compon. caution if pulmonary impairment

caution if sleep apnea

caution if CNS depression

caution if alcohol use

caution if alcohol or drug abuse hx

avoid abrupt withdrawal

caution if seizure hx

caution if renal impairment

caution if hepatic impairment

caution in elderly or debilitated pts

caution if depression

caution if smoking habit changes

caution if elevated gastric pH (ODT form)

caution if salivary flow decr. (ODT form)

caution if PKU (phenylalanine-containing forms)

Drug Interactions

Contraindicated

boceprevircontraindicated for oral benzodiazepines, consider decr. parenteral midazolam dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

chloramphenicolcontraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

clarithromycinscontraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)[clarithromycins: clarithromycin, lansoprazole/amoxicillin/clarithromycin, omeprazole/clarithromycin/amoxicillin]

cobicistatcontraindicated for oral midazolam, caution advised w/ injectable midazolam: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)[cobicistat: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil]

conivaptancontraindicated during and x7 days after conivaptan tx: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

cyclosporinecontraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)[cyclosporine: cyclosporine modified, cyclosporine non-modified]

delavirdinecontraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

efavirenzcontraindicated: combo may alter benzodiazepine levels, incr. risk of CNS depression, psychomotor impairment (hepatic metab. altered, additive effects)

efavirenz/emtricitabine/tenofovir disoproxilcontraindicated: combo w/ efavirenz may alter benzodiazepine levels, incr. risk of CNS depression, other adverse effects (hepatic metab. altered, additive effects)

fluvoxaminecontraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

HIV protease inhibitorscontraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)[HIV protease inhibitors: atazanavir, darunavir, fosamprenavir, indinavir, lopinavir/ritonavir, nelfinavir, ritonavir, saquinavir, tipranavir]

imatinibcontraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

isoniazidcontraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

itraconazolecontraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

ketoconazolecontraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

mifepristonecontraindicated w/in 14 days of mifepristone use; caution advised if pregnancy termination use: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

posaconazolecontraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

sodium oxybatecontraindicated: combo may incr. risk of CNS and resp. depression, other adverse effects (additive effects)

telaprevircontraindicated for oral benzodiazepines, consider decr. parenteral midazolam dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

telithromycincontraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

voriconazolecontraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

Avoid/Use Alternative

amiodaroneuse alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

aprepitantuse alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)[aprepitant: aprepitant, fosaprepitant]

calcium channel blockers, othersuse alternative or consider lower benzodiazepine dose: combo w/ verapamil, diltiazem may incr. risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)[calcium channel blockers, others: diltiazem, trandolapril/verapamil, verapamil]

ciprofloxacinuse alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, other adverse effects (hepatic metab. inhibited)

crizotinibavoid combo or use alternative: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

danazoluse alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

dronedaroneuse alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, other adverse effects (hepatic metab. inhibited)

erythromycinsuse alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)[erythromycins: erythromycin base, erythromycin ethylsuccinate, erythromycin lactobionate, erythromycin stearate, erythromycin/sulfisoxazole]

fluconazoleuse alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

grapefruituse alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (gastrointestinal metab. inhibited)[grapefruit: Citrus paradisi, grapefruit (Citrus paradisi), pomelo, toronja]

nefazodoneuse alternative or decr. alprazolam dose 50%: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited; additive effects)

pazopanibavoid combo: combo may incr. benzodiazepine levels, risk of CNS depression, other adverse effects (hepatic metab. inhibited)

propoxypheneuse alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited;

additive effects)[propoxyphene: propoxyphene hydrochloride, propoxyphene napsylate]

propoxyphene/acetaminophenuse alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited; additive effects)[propoxyphene/acetaminophen: propoxyphene hydrochloride/acetaminophen, propoxyphene napsylate/acetaminophen]

rifampinuse alternative: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)

rifampin/isoniaziduse alternative: combo w/ isoniazid may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment; combo w/ rifampin may decr. benzodiazepine levels, efficacy (hepatic metab. inhibited by isoniazid, induced by rifampin)

rifampin/isoniazid/pyrazinamideuse alternative: combo w/ isoniazid may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment; combo w/ rifampin may decr. benzodiazepine levels, efficacy (hepatic metab. inhibited by isoniazid, induced by rifampin)

tamoxifenuse alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

Monitor/Modify Tx

aripiprazolecaution advised, monitor BP and sedation if parenteral forms used together: combo may incr. risk of CNS depression, psychomotor impairment, orthostatic hypotension (additive effects)

dexmedetomidinecaution advised, consider dose reduction: combo may incr. risk of CNS depression, other adverse effects (additive effects)

propofolcaution advised, consider propofol dose reduction: combo may incr. risk of CNS and resp. depression, profound sedation, hypotension, other adverse effects (additive effects)[propofol: fospropofol, propofol]

Therapeutic Advantage

flumazeniluse for therapeutic advantage: combo will reverse sedation, other benzodiazepine effects (antagonistic effects)

Caution Advised

acetaminophen/caffeine/CNS depressant comboscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[acetaminophen/caffeine/CNS depressant combos: acetaminophen/caffeine/dihydrocodeine, butalbital/acetaminophen/caffeine, butalbital/acetaminophen/caffeine/codeine]

acetaminophen/chlorpheniraminecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

acetaminophen/chlorpheniramine/dextromethorphancaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

acetaminophen/chlorpheniramine/dextromethorphan/phenylephrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

acetaminophen/chlorpheniramine/phenylephrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

acetaminophen/diphenhydraminecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

acetaminophen/diphenhydramine/dextromethorphancaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

acetaminophen/diphenhydramine/phenylephrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

acetaminophen/doxylamine/dextromethorphancaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

acetaminophen/doxylamine/dextromethorphan/phenylephrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

acetaminophen/doxylamine/dextromethorphan/pseudoephedrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

acetaminophen/doxylamine/phenylephrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

acetaminophen/pheniramine/phenylephrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

aldesleukincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

antihistamine/decongestant comboscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[antihistamine/decongestant combos: acrivastine/pseudoephedrine, brompheniramine/phenylephrine, chlorpheniramine/phenylephrine, chlorpheniramine/pseudoephedrine, diphenhydramine/phenylephrine]

antihistamines, sedatingcaution advised: combo may incr. risk of CNS depression (additive effects)[antihistamines, sedating: brompheniramine, carbinoxamine, chlorpheniramine, clemastine, cyclizine, cyproheptadine, dexchlorpheniramine, dimenhydrinate, diphenhydramine, doxylamine, hydroxyzine, meclizine, triprolidine]

apomorphinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

artemether/lumefantrinecaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)

asenapinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

aspirin/chlorpheniramine/dextromethorphancaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

aspirin/chlorpheniramine/dextromethorphan/phenylephrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

aspirin/chlorpheniramine/phenylephrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

aspirin/diphenhydraminecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

aspirin/doxylamine/dextromethorphan/phenylephrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

azelastine nasalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal]

barbituratescaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)[barbiturates: butabarbital, methohexital, pentobarbital, phenobarbital, primidone, secobarbital, thiopental]

belataceptcaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. possibly altered; belatacept may normalize hepatic enzyme formation suppressed by incr. cytokine levels)

benzodiazepines, allcaution advised: combo may incr. risk of CNS depression, other adverse effects (additive effects)[benzodiazepines, all: alprazolam, chlordiazepoxide, clobazam, clonazepam, clorazepate, diazepam, diazepam rectal, estazolam, flurazepam, lorazepam, midazolam, oxazepam, temazepam, triazolam]

bexarotenecaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)

bosentancaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)

brompheniramine/dextromethorphan/phenylephrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

brompheniramine/dextromethorphan/pseudoephedrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

butalbital/acetaminophencaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

calendulacaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[calendula: bride of the sun, calendula (Calendula officinalis), Calendula officinalis, garden marigold, gold-bloom, golden flower of Mary, holligold, marigold, marybud, pot marigold]

cannabinoidscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[cannabinoids: dronabinol, nabilone]

capsicumcaution advised: combo w/ opioids may incr. risk of sedation, other adverse effects (additive effects)[capsicum: African chilies, capsaicin, capsicum (Capsicum annuum), Capsicum annuum, cayenne, chili pepper, green chili pepper, Louisiana long pepper, Mexican chilies, paprika, pimento, red pepper, tabasco pepper]

carbamazepinecaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

carisoprodol/aspirincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

cat's clawcaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, other adverse effects (hepatic metab. possibly inhibited)[cat's claw: cat's claw (Uncaria spp.), garbato casha, life-giving vine of Peru, paraguaya, samento, tambor hausca, una de gato, una de gavilan, Uncaria guianensis, Uncaria tomentosa]

central alpha 2 agonistscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[central alpha 2 agonists: clonidine, clonidine transdermal, guanabenz, guanfacine, methyldopa]

cetirizinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

cetirizine/pseudoephedrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

chamomile, Germancaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[chamomile, German: chamomile, German (Matricaria recutita), chamomile, Hungarian, chamomile, wild, Chamomilla recutita, Matricaria chamomilla, Matricaria recutita, pin heads]

chlorpheniramine/dextromethorphancaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

chlorpheniramine/dextromethorphan/pseudoephedrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

chlorpheniramine/hydrocodonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

cimetidinecaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

clozapinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, other adverse effects; cardiac/respiratory arrest/collapse reported w/ clozapine and some psychotropics (additive effects)

CNS depressant/aspirin/caffeine comboscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[CNS depressant/aspirin/caffeine combos: butalbital/aspirin/caffeine, butalbital/aspirin/caffeine/codeine, dihydrocodeine/aspirin/caffeine]

contraceptives, oral combocaution advised: combo w/ estrogen may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)[contraceptives, oral combo: desogestrel/ethinyl estradiol, drospirenone/ethinyl estradiol, drospirenone/ethinyl estradiol/levomefolate, estradiol valerate/dienogest, ethynodiol/ethinyl estradiol, levonorgestrel/ethinyl estradiol, norethindrone/ethinyl estradiol, norethindrone/mestranol, norgestimate/ethinyl estradiol, norgestrel/ethinyl estradiol]

contraceptives, other combocaution advised: combo w/ estrogen may incr. benzodiazepine levels, risk of CNS depression, other adverse effects (hepatic metab. inhibited)

[contraceptives, other combo: etonogestrel/ethinyl estradiol vaginal, norelgestromin/ethinyl estradiol transdermal]

dantrolenecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

dasatinibcaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

deferasiroxcaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)

dexamethasonecaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)[dexamethasone: dexamethasone, dexamethasone sodium phosphate]

doxylamine/dextromethorphancaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

droperidolcaution advised: combo may incr. risk of CNS depression, QT prolongation and arrhythmias (additive effects, mechanism unknown)

enzalutamidecaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)

ethanolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

ethosuximidecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

etomidatecaution advised: combo may incr. risk of CNS and resp. depression, psychomotor impairment (additive effects)

etravirinecaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)

ezogabinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

fluoxetinecaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

gabapentincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[gabapentin: gabapentin, gabapentin enacarbil]

ginseng, Siberiancaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[ginseng, Siberian: Acanthopanax senticosus, devil's bush, eleuthero, eleutherococcus, Eleutherococcus senticosus, ginseng, Siberian (Eleutherococcus senticosus), shigoka, thorny pepperbush, Touch-Me-Not, untouchable, wild pepper]

goldensealcaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[goldenseal: berberine, eye balm, eye root, goldenseal (Hydrastis canadensis), ground raspberry, Hydrastis canadensis, Indian plant, jaundice root, orange root, wild curcuma, yellow root]

gotu kolacaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[gotu kola: brahma-buti, Centella asiatica, gotu kola (Centella asiatica), hydrocotyle, Indian pennywort, Indian water navelwort, madescassol, marsh penny, talepetrako, thick-leaved pennywort, white rot]

green teacaution advised: combo may decr. sedative effects of benzodiazepines due to caffeine in green tea (antagonistic effects)[green tea: Camellia sinensis, Camellia thea, Chinese tea, green tea (Camellia sinensis), green tea extract, GTE, Japanese tea, Matsu-cha tea, Theaceae, theifers]

griseofulvinscaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)[griseofulvins: griseofulvin microsize, griseofulvin ultramicrosize]

guaranacaution advised: combo may decr. sedative effects of benzodiazepines due to caffeine in guarana (antagonistic effects)[guarana: Brazilian cocoa, guarana (Paullinia cupana), guarana gum, guarana paste, guaranine, Paullinia cupana, Uabano, Uaranzeiro, zoom]

haloperidolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[haloperidol: haloperidol, haloperidol decanoate, haloperidol lactate]

hawthorncaution advised: combo may incr. risk of CNS depressant effects (additive effects)[hawthorn: aubepine, Chinese hawthorn, Crataegus laevigata, Crataegus monogyna, Crataegus oxyacantha, Crataegus pentagyna, English hawthorn, hawthorn (Crataegus spp.), hedgethorn, maybush, maythorn, oneseed hawthorn, shanzha, whitehorn]

hydrocodone/chlorpheniramine/pseudoephedrinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive effects)

hydrocodone/ibuprofencaution advised, interaction more likely w/ IV benzodiazepines and IV opioids: combo may result in vasodilation, severe hypotension, CNS and respiratory depression, psychomotor impairment (additive effects)

hydrocodone/pseudoephedrinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive effects)

iloperidonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

inhaled anestheticscaution advised: combo may incr. risk of CNS and resp. depression, psychomotor impairment (additive effects)[inhaled anesthetics: desflurane, enflurane, isoflurane, sevoflurane]

kavacaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[kava: ava pepper, awa, intoxicating pepper, kao, kava (Piper methysticum), kawa, kew, Piper methysticum, sakau, tonga, yagona]

ketaminecaution advised: combo may incr. risk of CNS and resp. depression, psychomotor impairment (additive effects)

lanreotidecaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

lapatinibcaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

lemon balmcaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[lemon balm: balm, bee balm, cure-all, dropsy plant, honey plant, lemon balm (Melissa officinalis), Melissa, Melissa folium, Melissa officinalis, sweet balm, sweet Mary]

levocetirizinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

licoricecaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. possibly inhibited)[licorice: alcacuz, Chinese licorice, gan cao, gan zao, Glycyrrhiza glabra, Lakritzenwurzel, licorice (Glycyrrhiza glabra), orozuz, Russian licorice, Spanish licorice, sweet root]

loxapinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment; hypotension/respiratory depression/stupor reported w/ loxapine and lorazepam (additive effects)

lurasidonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

maprotilinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

meprobamatecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

methadonecaution advised, especially w/ IV benzodiazepines and IV opioids, consider dose reduction: combo may result in vasodilation, severe hypotension, CNS and respiratory depression, psychomotor impairment (additive effects)

metoclopramidecaution advised: combo may incr. risk of CNS depression (additive effects)

mirtazapinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

mitotanecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

modafinilcaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)[modafinil: armodafinil, modafinil]

morphine liposomalcaution advised: combo may incr. risk of CNS and resp. depression, profound sedation, hypotension, other adverse effects (additive effects)

muscle relaxantscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[muscle relaxants: baclofen, baclofen intrathecal, carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine, tizanidine]

naproxen/esomeprazolecaution advised w/ alprazolam ODT form: combo w/ esomeprazole may decr. alprazolam levels, delay effects (disintegration/dissolution, absorption slowed or decreased if gastric pH elevated)

nevirapinecaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)

nilotinibcaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

NSAID/chlorpheniramine/pseudoephedrine comboscaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)[NSAID/chlorpheniramine/pseudoephedrine combos: ibuprofen/chlorpheniramine/pseudoephedrine]

NSAID/diphenhydramine comboscaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)[NSAID/diphenhydramine combos: ibuprofen/diphenhydramine]

octreotidecaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. possibly inhibited)

olanzapinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive effects)

olanzapine/fluoxetinecaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited; additive effects)

olopatadine nasalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

opiate agonist/antagonistscaution advised, consider lower doses: combo may incr. risk of CNS and resp. depression, psychomotor impairment (additive effects)[opiate agonist/antagonists: buprenorphine, buprenorphine transdermal, buprenorphine/naloxone, butorphanol, butorphanol nasal, nalbuphine, pentazocine lactate, pentazocine/naloxone]

opiate/acetaminophen comboscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[opiate/acetaminophen combos: acetaminophen/codeine, hydrocodone/acetaminophen, oxycodone/acetaminophen, pentazocine/acetaminophen]

opiate/aspirin comboscaution advised: combo may incr. risk of CNS and resp. depression, psychomotor impairment (additive effects)[opiate/aspirin combos: carisoprodol/aspirin/codeine, oxycodone/aspirin]

opiatescaution advised, especially w/ IV benzodiazepines and IV opioids, consider dose reduction: combo may result in vasodilation, severe hypotension, CNS and respiratory depression, psychomotor impairment (additive effects)[opiates: alfentanil, codeine phosphate, codeine sulfate, codeine/guaifenesin, fentanyl, fentanyl nasal, fentanyl transdermal, fentanyl transmucosal, hydrocodone/homatropine, hydromorphone, levorphanol, meperidine, morphine sulfate, morphine sulfate/naltrexone, oxycodone, oxymorphone, remifentanil, sufentanil]

oxcarbazepinecaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

oxycodone/ibuprofencaution advised, interaction more likely w/ IV benzodiazepines and IV opioids: combo may result in vasodilation, severe hypotension, CNS and respiratory depression, psychomotor impairment (additive effects)

paliperidonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[paliperidone: paliperidone, paliperidone palmitate]

passionflowercaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[passionflower: apricot vine, corona de cristo, Fleischfarbige, fleur de la passion, maypop, Passiflora incarnata, passion vine, passionflower (Passiflora incarnata), purple passion flower, water lemon, wild passion flower]

pheniramine/dextromethorphan/phenylephrinecaution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

phenobarbital/hyoscyamine/atropine/scopolaminecaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

phenothiazinescaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[phenothiazines: chlorpromazine, fluphenazine, fluphenazine decanoate, perphenazine, prochlorperazine edisylate, prochlorperazine maleate, prochlorperazine rectal, promethazine, promethazine rectal, thioridazine, trifluoperazine]

phenytoinscaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)[phenytoins: fosphenytoin, phenytoin]

pimozidecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

pramipexolecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

pregabalincaution advised: combo may incr. risk of CNS depression, psychomotor impairment, adverse effects (additive effects)

promethazine/codeinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

quetiapinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

quinine sulfatecaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, other adverse effects (hepatic metab. inhibited)

quinupristin/dalfopristincaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

ranolazinecaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, other adverse effects (hepatic metab. inhibited)

red clovercaution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. possibly inhibited)[red clover: beebread, cow clover, daidzein, genistein, meadow clover, purple clover, red clover (Trifolium pratense), trefle des pres, trefoil, Trifolium pratense, wild clover]

rifabutincaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)

rifapentinecaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)

risperidonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

ropinirolecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

rotigotine transdermalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

rufinamidecaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

sedative/hypnoticscaution advised, consider sedative/hypnotic dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[sedative/hypnotics: chloral hydrate, eszopiclone, zaleplon, zolpidem]

St. John's wortcaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)[St. John's wort: amber, amber touch-and-heal, balm-of-warrior's wound, balsana, demon chaser, goatweed, Hypericum perforatum, Klamath weed, millepertuis, rosin rose, St. John's wort (Hypericum perforatum), Tipton weed, witcher's herb]

tapentadolcaution advised, consider lower doses: combo may incr. risk of CNS and resp. depression, psychomotor impairment (additive effects)

tetrabenazinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

thalidomidecaution advised: combo may incr. risk of CNS depression (additive effects)

thiothixenecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

tiagabinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

TNF blocking agentscaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. altered; TNF blockers may inhibit inflammatory cytokine-induced downregulation of CYP450 enzymes resulting in relative induction of enzymes upon tx start and downregulation upon D/C)[TNF blocking agents: adalimumab, certolizumab pegol, etanercept, golimumab, infliximab]

tocilizumabcaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. altered; tocilizumab may inhibit inflammatory cytokine-induced downregulation of CYP450 enzymes resulting in relative induction of enzymes upon tx start and downregulation upon D/C)

topiramatecaution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)[topiramate: phentermine hydrochloride/topiramate, topiramate]

tramadolcaution advised, consider lower tramadol dose: combo may incr. risk of CNS and resp. depression, psychomotor impairment (additive effects)

tramadol/acetaminophencaution advised: combo w/ tramadol may incr. risk of CNS and respiratory depression, psychomotor impairment (additive effects)

trazodonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

tricyclic antidepressantscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[tricyclic antidepressants: amitriptyline, amoxapine, chlordiazepoxide/amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, perphenazine/amitriptyline, protriptyline, trimipramine]

ustekinumabcaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. possibly altered; ustekinumab may normalize hepatic enzyme formation suppressed by incr. cytokine levels)

valeriancaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[valerian: all-heal, amantilla, baldrian, baldrianwurzel, garden heliotrope, herba benedicta, valerian (Valeriana officinalis), Valeriana edulis, Valeriana jatamansii, Valeriana officinalis, Valeriana sitchensis, Valeriana wallichii]

valproic acid derivativescaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid]

vemurafenibcaution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced)

vigabatrincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

ziconotide intrathecalcaution advised: combo may incr. risk of confusion, dizziness, other CNS adverse effects (additive effects)[ziconotide intrathecal: ziconotide]

ziprasidonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

zonisamidecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

Adverse Reactions

Serious Reactions

respiratory depression dependency, abuse

withdrawal if abrupt D/C

seizures

suicidality

tachycardia

hypotension

syncope

CNS stimulation, paradoxical

hepatotoxicity

Stevens-Johnson syndrome

angioedema

Common Reactions

drowsiness fatigue

impaired coordination

irritability

amnesia

appetite change

confusion

dysarthria

dizziness

impaired concentration

xerostomia

libido changes

urinary retention

menstrual irregularities

sialorrhea

hypotension

rash

diplopia

LFTs elevated

disinhibition

incontinence

Safety/Monitoring

Pregnancy: D (Positive evidence of human fetal risk; maternal benefit may outweigh fetal risk in serious or life-threatening situations; see pkg insert for drug-specific recs)

Lactation: Possibly Unsafe (Available animal and/or human data demonstrates potential or actual adverse effects to infant/breast milk production; consider alternatives or weigh risk/benefit)

Monitoring Parameters LFTs if prolonged tx

Avoid Abrupt Cessation taper dose gradually to D/C if at risk for physical dependence (abrupt cessation of benzodiazepines or barbiturates may cause a withdrawal syndrome including irritability, anxiety, agitation, dysphoria, confusion, memory deficits, hallucinations, sensory disturbances, paresthesia, psychosis, seizures, insomnia, tremors, muscle twitching, muscle cramps, abdominal cramps, GI disturbances, tachycardia, diaphoresis)

Look/Sound-Alike Drug Names [from www.usp.org]

alprazolam confused with: Ativan; clonazepam; diazepam; lorazepam

Pharmacology

Metabolism: liver; CYP450: 3A4 substrate; Info: minor active metabolite

Excretion: urine; Half-life: 11.2h, 16.3h (elderly), 19.7h (alcoholic liver dz)

Subclass: Benzodiazepines 1: Short-acting

Mechanism of Actionbinds to benzodiazepine receptors; enhances GABA effects

Manufacturer/Pricing

Manufacturer: generic

DEA/FDA: Schedule IV: (Requires prescription; low/moderate abuse potential; max 5 refills/6mo; verbal orders allowed; some states may impose restrictions)

Approximate Retail Price

from  www.drugstore.com

tablet:

0.25 mg (30 ea): $11.99 0.5 mg (30 ea): $12.99

1 mg (30 ea): $12.99

2 mg (30 ea): $15.99

tablet, dispersible:

0.25 mg (30 ea): $43.99 1 mg (30 ea): $69.99

tablet extended release, 24 hr:

0.5 mg (30 ea): $31.99 1 mg (30 ea): $69.99

2 mg (30 ea): $75.99

3 mg (30 ea): $109.98

Patient Education

Nombre Genérico: alprazolam

Nombres de las Marcas: Niravam, Xanax, Xanax XR

¿Cuál es la información más importante que debo saber sobre alprazolam?

No use alprazolam si usted está embarazada. Le puede causar daño al bebé nonato.

No use esta medicina si tiene alergia a alprazolam o a otro benzodiazepínico, como chlordiazepoxide (Librium), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), o oxazepam (Serax).

Antes de tomar alprazolam, dígale a su médico si usted tiene algún problema con la respiración, glaucoma, enfermedad del riñón o del hígado, o historial de depresión, pensamientos de querer suicidarse, o adicción a drogas o al alcohol.

No beba alcohol mientras esté tomando alprazolam. Esta medicina puede aumentar los efectos del alcohol.

Alprazolam puede crear dependencia, y solamente debe ser usada por la persona para quien ha sido recetada. Mantenga la medicina en un lugar seguro donde otros no la puedan obtener.

¿Qué es alprazolam?

Alprazolam es un benzodiazepínico. Alprazolam afecta los químicos en el cerebro que pueden salir de su equilibrio y causarle ansiedad.

Alprazolam se usa para el tratamiento de trastornos de la ansiedad, trastornos de pánico, y la ansiedad causada por la depresión.

Alprazolam puede también usarse para fines no mencionados en esta guía del medicamento.

¿Qué debería discutir con el profesional de la salud antes de tomar alprazolam?

Es peligroso comprar alprazolam por el Internet o a través de vendedores situados fuera de los Estados Unidos de Norteamérica. Las medicinas distribuidas por el Internet pueden contener ingredientes peligrosos, o pueden ser distribuidos por farmacias sin licencia. Se han encontrado muestras de alprazolam obtenidas por el Internet con haloperidol (Haldol), una droga fuerte antipsicótica que tiene efectos secundarios graves. Para más información, comuníquese con la U.S. Food and Drug Administration (FDA) o visite www.fda.gov/buyonlineguide.

Usted no debe tomar alprazolam si usted tiene:

glaucoma de ángulo estrecho; si también está tomando itraconazole (Sporanox) o ketoconazole (Nizoral); o

tiene alergia a alprazolam o a otro benzodiazepínico, como chlordiazepoxide (Librium), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), o oxazepam (Serax).

Para asegurarse que usted puede tomar alprazolam de forma segura, dígale a su médico si usted tiene cualquiera de estas otras condiciones:

asma, enfisema, bronquitis, enfermedad pulmonar obstructiva crónica (EPOC; COPD por sus siglas in inglés), u otro problema con la respiración;

glaucoma;

enfermedad del riñón o del hígado (en particular enfermedad del hígado por alcoholismo);

historial de depresión o pensamientos de querer suicidarse o tomar acciones para tal fin; o

historial de adicción a la droga o al alcohol.

Alprazolam puede crear hábito y debería ser usado solamente para la persona a quien se le recetó. Nunca comparta alprazolam con otra persona, especialmente con alguien con historial de abuso de drogas o adicción. Mantenga el medicamento en un lugar donde otros no lo puedan encontrar.

Categoría D del embarazo por la FDA. No use alprazolam si usted está embarazada. Le puede causar daño al bebé nonato. Alprazolam puede también causar adicción o síntomas de abstinencia en un recién nacido si la madre toma el medicamento durante el embarazo. Use un método efectivo de control de la natalidad, y dígale a su médico si usted queda embarazada durante el tratamiento.

Alprazolam puede pasar a la leche materna y causarle daño al bebé lactante. Usted no debe amamantar mientras está usando alprazolam.

Los efectos sedativos de alprazolam pueden durar más tiempo en los adultos de edad avanzada. Caídas accidentales ocurren comúnmente en los ancianos que toman benzodiazepínicos. Tome medidas de precaución para evitar caerse o herirse accidentalmente mientras esté tomando alprazolam.

No le dé esta medicina a nadie menor de los 18 años.

¿Cómo debo tomar alprazolam?

Tómelo exactamente como lo haya recetado su médico. No lo tome en cantidades mayores o menores, o por más tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su

prescripción. Tal vez su médico en ocasiones cambie su dosis para asegurarse de que está obteniendo los mejores resultados.

No triture, mastique, o rompa una tableta de liberación prolongada. Trague la pastilla entera. Ésta ha sido preparada de forma especial para liberar la medicina lentamente al cuerpo. Si la rompe, causaría que salga la medicina junta.

Mida la formulación líquida de alprazolam con una cuchara especial de medir o taza, y no con una cuchara regular de sopa. Si no tiene con que medir su dosis, pídale una a su farmacéutico.

No se trague entera la tableta oral que se desintegra. Deje que se disuelva en la boca sin tener que masticar.

Hable con su médico si le parece que esta medicina ha dejado de funcionar para tratar sus síntomas de pánico o ansiedad.

Usted puede tener convulsiones o el síndrome de abstinencia cuando pare de usar alprazolam. Pregúntele a su médico cómo evitar los síntomas de abstinencia cuando pare de usar alprazolam.

Mantenga un record de la cantidad de medicina que ha usado de cada envase nuevo. Alprazolam es una droga de potencial de abuso y usted debería saber si alguien está usando su medicina inapropiadamente o sin prescripción.

Guarde a temperatura ambiente fuera de la humedad y del calor.

¿Qué sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sáltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome más medicina para alcanzar la dosis pasada.

¿Qué sucedería en una sobredosis?

Busque atención médica de emergencia o llame a la línea de Poison Help al 1-800-222-1222. La sobredosis de alprazolam podría ser fatal. Los síntomas pueden incluir somnolencia extrema, confusión, debilidad musculares, perdida de balance o coordinación, sensación de desvanecimiento, y desmayo.

¿Qué debo evitar mientras tomo alprazolam?

No beba alcohol mientras esté tomando alprazolam. Esta medicina puede aumentar los efectos del alcohol.

Alprazolam puede perjudicar su pensamiento o reacciones. Tenga cuidado si usted conduce un vehículo o tiene que hacer algo que demande se mantenga alerta.

La toronja y el jugo de toronja pueden tener interacciones con alprazolam y potencialmente causar efectos graves. Hable con su médico acerca del uso de productos de toronja.

¿Cuáles son los efectos secundarios posibles de alprazolam?

Busque atención médica de emergencia si nota alguno de estos síntomas de una reacción alérgica: ronchas; dificultad para respirar; hinchazón de la cara, labios, lengua, o garganta.

Deje de usar alprazolam y llame a su médico de inmediato si usted tiene un efecto secundario grave como:

depresión, piensa en suicidarse o hacerse daño, inusual comportamiento de alto riesgo, disminución de las inhibiciones, perder el miedo al peligro;

confusión, hiperactividad, agitación, hostilidad, alucinaciones;

sentir que se puede desmayar;

orinar menos de lo usual o nada en absoluto;

dolor de pecho, latidos cardíacos fuertes o aleteo cardíaco en su pecho;

movimientos musculares descontrolados, temblores, convulsiones; o

ictericia (color amarillo de la piel u ojos).

Efectos secundarios de menor gravedad pueden incluir:

somnolencia, mareo, sentirse cansado o irritable; visión borrosa, dolor de cabeza, problemas de la memoria, dificultad para concentrarse;

problemas para dormir (insomnio);

hinchazón en sus manos o pies;

debilidad muscular, falta de balance o coordinación, habla arrastrado;

malestar estomacal, náusea, vómito, estreñimiento, diarrea;

aumento del sudor, boca seca, nariz tupida; o

cambios en el apetito o el peso, pérdida de interés en la actividad sexual.

Esta lista no menciona todos los efectos secundarios y puede ser que ocurran otros. Llame a su médico para consejos médicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

¿Qué otras drogas afectarán a alprazolam?

Antes de usar alprazolam, dígale a su médico si usted usa con regularidad otras drogas que causan somnolencia (como medicinas para el resfriado o alergias, otras sedantes, narcóticos para el control del dolor, pastillas para dormir, relajantes musculares, y medicinas para las convulsiones, depresión, o ansiedad). Estas pueden añadir a la somnolencia que causa alprazolam.

Dígale a su médico acerca de todas las medicinas que usted use, especialmente:

pastillas anticonceptivas; cyclosporine (Gengraf, Neoral, Sandimmune);

dexamethasone (Cortastat, Dexasone, Solurex, DexPak);

ergotamine (Cafergot, Ergomar, Migergot);

imatinib (Gleevec);

isoniazid (para tratar la tuberculosis);

St. John's wort;

un antibiótico como clarithromycin (Biaxin), erythromycin (E.E.S., EryPed, Ery-Tab, Erythrocin, Pediazole), rifabutin (Mycobutin), rifampin (Rifadin, Rifater, Rifamate), rifapentine (Priftin), o telithromycin (Ketek);

medicamento antifúngico como miconazole (Oravig) o voriconazole (Vfend);

un antidepresivo como fluoxetine (Prozac, Sarafem, Symbyax), fluvoxamine (Luvox), desipramine (Norpramin), imipramine (Janimine, Tofranil), o nefazodone;

un barbitúrico como butabarbital (Butisol), secobarbital (Seconal), pentobarbital (Nembutal), o phenobarbital (Solfoton);

medicamento para el corazón o la presión arterial como amiodarone (Cordarone, Pacerone), diltiazem (Tiazac, Cartia, Cardizem), nicardipine (Cardene), nifedipine (Nifedical, Procardia), o quinidine (Quin-G);

medicinas para el tratamiento del VIH o SIDA como atazanavir (Reyataz), delavirdine (Rescriptor), efavirenz (Sustiva, Atripla), etravirine (Intelence), indinavir (Crixivan), nelfinavir (Viracept), nevirapine (Viramune), saquinavir (Invirase), o ritonavir (Norvir, Kaletra); o

medicamento para las convulsiones como carbamazepine (Carbatrol, Equetro, Tegretol), felbamate (Felbatol), oxcarbazepine (Trileptal), phenytoin (Dilantin), o primidone (Mysoline).

Esta lista no incluye todas las drogas y pueden existir otras que tengan interacciones con alprazolam. Dígale a su médico acerca de todos los medicamentos que usted use. Incluya los productos que se obtienen con o sin receta, vitaminas, y productos herbarios. No empiece a usar un medicamento nuevo sin primero decirle a su médico.

¿Dónde puedo obtener más información?

Su farmacéutico le puede dar más información sobre alprazolam (Xanax).

Drug

clopidogrelgeneric

Entire Monograph

Black Box Warnings

Diminished Efficacy in Poor Metabolizers

clopidogrel efficacy dependent on conversion to active metabolite by CYP450 enzymes, principally CYP2C19; less active metabolite formed and smaller anti-platelet effect observed in CYP2C19 poor metabolizers on recommended clopidogrel doses; poor metabolizers w/ ACS or undergoing PCI had higher cardiovascular event rates than in pts w/ normal CYP2C19 fxn; CYP2C19 genotype tests are avail. and may assist in tx strategy; consider alternative dosing strategies or other anti-platelet tx in CYP2C19 poor metabolizers

Adult Dosing

Dosage forms:  75,300

acute coronary syndrome

[75 mg PO qd]Start: 300 mg PO x1; Info: start dose optional for pts w/ STEMI; give w/ aspirin 75-325 mg PO qd; may use w/ heparin acutely; consider CYP2C19 genotyping; may consider incr. dose in CYP2C19 poor metabolizers

thrombotic event prevention

[75 mg PO qd]Info: for pts w/ recent MI, recent stroke, or peripheral arterial dz; consider CYP2C19 genotyping; may consider incr. dose in CYP2C19 poor metabolizers

renal dosing

[not defined]mod-severe impairment: caution advised; HD: not defined

hepatic dosing

[no adjustment]

Peds Dosing

Peds dosing is currently unavailable or not applicable for this drug.

Contraindications/Cautions

hypersens. to drug/class/compon. active bleeding

caution if trauma

caution if elective surgery w/in 5 days

caution if GI disorder

caution if ocular dz

caution if poor or intermediate CYP2C19 metabolizer

caution if renal impairment, mod-severe

Drug Interactions

Avoid/Use Alternative

acetaminophen/aspirinweigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects)

acetaminophen/aspirin/caffeineweigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects)

antiplateletsweigh risk/benefit: combo may incr. risk of bleeding (additive effects)[antiplatelets: anagrelide, cilostazol, clopidogrel, dipyridamole, prasugrel, ticagrelor, ticlopidine]

aspirinweigh risk/benefit, low dose ASA OK: combo may incr. risk of bleeding (additive effects)

aspirin/caffeineweigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects)

aspirin/calcium carbonateweigh risk/benefit, low dose ASA OK: combo may incr. risk of bleeding (additive effects)

aspirin/chlorpheniramine/dextromethorphanweigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects)

aspirin/chlorpheniramine/dextromethorphan/phenylephrineweigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects)

aspirin/chlorpheniramine/phenylephrineweigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects)

aspirin/diphenhydramineweigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects)

aspirin/dipyridamoleweigh risk/benefit: combo may incr. risk of bleeding (additive effects)

aspirin/doxylamine/dextromethorphan/phenylephrineweigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects)

aspirin/phenylephrineweigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects)

carisoprodolavoid combo: combo may incr. carisoprodol levels, risk of adverse effects (hepatic metab. inhibited)

carisoprodol/aspirinavoid combo: combo w/ aspirin may incr. risk of bleeding; combo may incr. carisoprodol levels, risk of adverse effects (additive antiplatelet effects; hepatic metab. inhibited)

carisoprodol/aspirin/codeineavoid combo: combo w/ aspirin may incr. risk of bleeding; combo may incr. carisoprodol levels, risk of adverse effects (additive antiplatelet effects; possibly decr. conversion of clopidogrel to active metabolite; hepatic metab. inhibited)

chloramphenicolavoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite)

cimetidineavoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite)

CNS depressant/aspirin/caffeine combosweigh risk/benefit: combo may incr. risk of bleeding (additive antiplatelet effects)[CNS depressant/aspirin/caffeine combos: butalbital/aspirin/caffeine, butalbital/aspirin/caffeine/codeine, dihydrocodeine/aspirin/caffeine]

danshenavoid combo: combo may incr. risk of bleeding (additive antiplatelet effects)[danshen: ch'ih shen, danshen (Salvia miltiorrhiza), huang ken, pin-ma ts'ao, red sage, saliva root, Salvia miltiorrhiza Bunge, shu-wei ts'ao, tan-shen, tzu tan-ken]

delavirdineavoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite)

drotrecogin alfaweigh risk/benefit if antiplatelets w/in 7 days prior to drotrecogin alfa: combo may incr. risk of bleeding (additive effects)

efavirenzavoid combo: combo may decr. clopidogrel efficacy; may incr. efavirenz levels, risk of adverse effects (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite; hepatic metab. inhibited)

efavirenz/emtricitabine/tenofovir disoproxilavoid combo: combo may incr. efavirenz levels, risk of adverse effects; combo w/ efavirenz may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite)

esomeprazoleavoid combo; consider H2 blocker: combo may decr. clopidogrel efficacy; may incr. proton pump inihibitor levels (possibly decr. conversion of clopidogrel to active metabolite; hepatic metab. inhibited)

etravirineavoid combo: combo may decr. clopidogrel efficacy; may incr. etravirine levels, risk of adverse effects (possibly decr. conversion of clopidogrel to active metabolite; hepatic metab. inhibited)

felbamateavoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite)

fluconazoleavoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite)

fluoxetineavoid combo: combo may incr. risk of bleeding; may decr. clopidogrel efficacy; may incr. SSRI levels, risk of adverse effects (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake; possibly decr. conversion of clopidogrel to active metabolite; hepatic metab. inhibited)

fluvoxamineavoid combo: combo may incr. risk of bleeding; may decr. clopidogrel efficacy

(synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake; possibly decr. conversion of clopidogrel to active metabolite; hepatic metab. inhibited)

fondaparinuxweigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)

heparinsweigh risk/benefit: combo may incr. risk of bleeding (additive effects)[heparins: dalteparin, enoxaparin, heparin, tinzaparin]

ibritumomab tiuxetanweigh risk/benefit, monitor platelets: combo may incr. risk of bleeding (additive effects, ibritumomab induces severe prolonged thrombocytopenia)

isoniazidavoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite)

ketoconazoleavoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite)

modafinilavoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite)[modafinil: armodafinil, modafinil]

naproxen/esomeprazoleavoid combo: combo w/ esomeprazole may decr. clopidogrel efficacy; combo may incr. proton pump inhibitor levels; combo w/ naproxen may incr. risk of bleeding (possibly decr. conversion of clopidogrel to active metabolite by esomeprazole; hepatic metab. inhibited; additive effects)

olanzapine/fluoxetineavoid combo: combo w/ clopidogrel may incr. fluoxetine levels, risk of adverse effects, may incr. risk of bleeding; combo may incr. olanzapine levels, risk of adverse effects; combo may decr. clopidogrel efficacy (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake; hepatic metab. inhibited; possibly decr. conversion of clopidogrel to active metabolite)

omeprazoleavoid combo; consider H2 blocker: combo may decr. clopidogrel efficacy; may incr. proton pump inihibitor levels (possibly decr. conversion of clopidogrel to active metabolite; hepatic metab. inhibited)[omeprazole: omeprazole, omeprazole/sodium bicarbonate]

omeprazole/clarithromycin/amoxicillinavoid combo; consider H2 blocker: combo w/ omeprazole may decr. clopidogrel efficacy; may incr. omeprazole levels (possibly decr. conversion of clopidogrel to active metabolite; hepatic metab. inhibited)

oseltamiviruse alternative: combo may decr. oseltamivir efficacy (hepatic metab. inhibited, decr. conversion to active oseltamivir metabolite)

oxcarbazepineavoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite)

oxycodone/aspirinweigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects)

pentosan polysulfate sodiumweigh risk/benefit: combo may incr. risk of bleeding (additive effects)

platelet GP IIb/IIIa inhibitorsweigh risk/benefit: combo may incr. risk of bleeding (additive antiplatelet effects)[platelet GP IIb/IIIa inhibitors: abciximab, eptifibatide, tirofiban]

rifampin/isoniazidavoid combo: combo w/ isoniazid may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite)

rifampin/isoniazid/pyrazinamideavoid combo: combo w/ isoniazid may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite)

rivaroxabanweigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)

thrombolyticsweigh risk/benefit: combo may incr. risk of bleeding (additive effects)[thrombolytics: alteplase, reteplase, tenecteplase]

tipranaviravoid combo: combo may incr. risk of bleeding; may decr. clopidogrel efficacy (additive antiplatelet effects; possibly decr. conversion of clopidogrel to active metabolite; hepatic metab. inhibited)

tositumomab and iodine I 131 tositumomab weigh risk/benefit, monitor platelets: combo may incr. risk of bleeding (additive effects, tositumomab induces severe prolonged thrombocytopenia)

voriconazoleavoid combo: combo may decr. clopidogrel efficacy; may incr. voriconazole levels, risk

of visual disturbances, other adverse effects (possibly decr. conversion of clopidogrel to active metabolite; hepatic metab. inhibited)

warfarinweigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)

Monitor/Modify Tx

bupropioncaution advised, adjust bupropion dose if needed: combo may incr. bupropion levels, risk of seizures, other adverse effects (hepatic metab. inhibited)[bupropion: bupropion hydrobromide, bupropion hydrochloride]

chamomile, Germancaution advised w/ large doses of German chamomile: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[chamomile, German: chamomile, German (Matricaria recutita), chamomile, Hungarian, chamomile, wild, Chamomilla recutita, Matricaria chamomilla, Matricaria recutita, pin heads]

citaloprammax citalopram dose 20 mg/day: combo may incr. citalopram levels, risk of QT prolongation, cardiac arrhythmias, serotonin syndrome, other adverse effects; may incr. risk of bleeding (hepatic metab. inhibited; synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake)

phenytoinscaution advised, monitor phenytoin levels: may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)[phenytoins: fosphenytoin, phenytoin]

pioglitazone/glimepiridemonitor glucose: combo may incr. sulfonylurea levels, risk of hypoglycemia (hepatic metab. inhibited)

red clovercaution advised w/ large doses of red clover: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects, red clover has coumarin constituents)[red clover: beebread, cow clover, daidzein, genistein, meadow clover, purple clover, red clover (Trifolium pratense), trefle des pres, trefoil, Trifolium pratense, wild clover]

tolbutamidemonitor glucose: combo may incr. tolbutamide levels, risk of hypoglycemia, other adverse effects (hepatic metab. inhibited)

Caution Advised

atovaquone/proguanilcaution advised: combo may decr. proguanil active metabolite levels, efficacy (hepatic metab. inhibited, decr. conversion to active metabolite)

bivalirudincaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)

bosentancaution advised unless combined w/ moderate or strong CYP3A4 inhibitor, then avoid combo: combo may incr. bosentan levels, risk of toxicity (hepatic metab. inhibited)

capsicumcaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[capsicum: African chilies, capsaicin, capsicum (Capsicum annuum), Capsicum annuum, cayenne, chili pepper, green chili pepper, Louisiana long pepper, Mexican chilies, paprika, pimento, red pepper, tabasco pepper]

clomipraminecaution advised: combo may incr. clomipramine levels, risk of adverse effects (hepatic metab. inhibited)

collagenase clostridium histolyticumcaution advised: combo may incr. risk of bleeding (additive effects)

cyclophosphamidecaution advised: combo may decr. cyclophosphamide active metabolite levels, efficacy (hepatic metab. inhibited, decr. conversion to active metabolite)

darunavircaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)

dasatinibcaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)

deferasiroxcaution advised: combo may incr. risk of GI bleeding (additive effects)

desipraminecaution advised: combo may incr. desipramine levels, risk of adverse effects (hepatic metab. inhibited)

desirudincaution advised: combo may incr. risk of bleeding (additive effects)

desvenlafaxinecaution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake)

diazepamcaution advised: combo may incr. diazepam levels, risk of adverse effects (hepatic metab. inhibited)[diazepam: diazepam, diazepam rectal]

diclofenac topicalcaution advised: combo may incr. risk of bleeding (additive antiplatelet effects, up to 10% systemic absorption of diclofenac topical; minimal absorption w/ patch)[diclofenac topical: diclofenac epolamine topical, diclofenac topical]

dong quaicaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[dong quai: Angelica atropurpurea, Angelica dahurica, Angelica sinensis, Chinese angelica, dang gui, dong quai (Angelica sinensis), ligustilides, Radix Angelicae Sinensis, tang-kuei]

doxepincaution advised: combo may incr. doxepin levels, risk of adverse effects (hepatic metab. inhibited)

duloxetinecaution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake)

escitalopramcaution advised: combo may incr. risk of bleeding; may incr. SSRI levels, risk of adverse effects (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake; hepatic metab. inhibited)

evening primrose oilcaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[evening primrose oil: evening primrose oil (Oenothera biennis), fever plant, king's cureall, night willow-herb, Oenothera biennis, scabish, stella di sera, sun drop]

fenugreekcaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[fenugreek: bird's foot, bockshornsamen, chilbe, fenugreek (Trigonella foenum-graecum), foenugraeci semen, Greek hay, griechische Heusamen, hu lu ba, methi, Trigonella foenum-graecum]

feverfewcaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[feverfew: altamisa, bachelor's button, camomille grande, Chrysanthemum parthenium, featherfew, featherfoil, feverfew (Tanacetum parthenium), flirtwort midsummer daisy, midsummer daisy, Santa Maria, Tanacetum parthenium]

flaxseedcaution advised w/ flaxseed oil: combo may incr. risk of bleeding (additive antiplatelet effects)[flaxseed: flax, flaxseed (Linum usitatissimum), graine de lin, leinsamen, lini semen, linoleic acid, linseed, lint bells, Linum usitatissimum]

fluvastatincaution advised: combo may incr. fluvastatin levels, risk of myopathy, rhabdomyolysis (hepatic metab. inhibited)

garliccaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[garlic: ail, ajo, Allium sativum, camphor of the poor, da-suan, garlic (Allium sativum), knoblauch, la-suan, nectar of the Gods, poor man's treacle, rust treacle, stinking rose]

gingercaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[ginger: African ginger, black ginger, cochin ginger, ginger (Zingiber officinale), Imber, Jamaica ginger, race ginger, rhizoma zingerberis, sheng jiang, Shokyo, Zingiber officinale, Zingiberis rhizoma]

ginkgo bilobacaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[ginkgo biloba: Eun-haeng, fossil tree, ginkgo (Ginkgo biloba), Ginkgo biloba, ginkyo, icho, ityo, Japanese silver apricot, kew tree, maidenhair tree, salisburia, silver apricot]

ginseng, Asiancaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[ginseng, Asian: ginseng radix, ginseng root, ginseng, Asian (Panax ginseng), ginseng, Chinese, ginseng, Japanese, ginseng, Korean, jintsam, ninjin, Panax ginseng, red ginseng, ren shen]

ginseng, Siberiancaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[ginseng, Siberian: Acanthopanax senticosus, devil's bush, eleuthero, eleutherococcus, Eleutherococcus senticosus, ginseng, Siberian (Eleutherococcus senticosus), shigoka, thorny pepperbush, Touch-Me-Not, untouchable, wild pepper]

green teacaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[green tea: Camellia sinensis, Camellia thea, Chinese tea, green tea (Camellia sinensis), green tea extract, GTE, Japanese tea, Matsu-cha tea, Theaceae, theifers]

horse chestnut seedcaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[horse chestnut seed: aescin, Aesculus hippocastanum, chestnut, de marronier d'Inde,

escine, hippocastani semen, horse chestnut seed (Aesculus hippocastanum), marronier, venostasin, venostat]

hydrocodone/ibuprofencaution advised: combo may incr. risk of bleeding (additive effects)

ibuprofen/famotidinecaution advised: combo w/ ibuprofen may incr. risk of bleeding (additive effects)

ifosfamidecaution advised: combo may alter ifosfamide active metabolite formation, efficacy; may decr. toxic metabolite formation, decr. risk of neurotoxicity (hepatic metab. inhibited, decr. active metabolite formation and inactivation, decr. formation of toxic metabolite)

iloprost inhaledcaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)

imipraminecaution advised: combo may incr. imipramine levels, risk of adverse effects (hepatic metab. inhibited)

ketaminecaution advised: combo may incr. ketamine levels, risk of CNS and resp. depression, other adverse effects (hepatic metab. inhibited)

meperidinecaution advised: combo may incr. meperidine levels, risk of respiratory depression, other adverse effects (hepatic metab. inhibited)

methadonecaution advised: combo may incr. methadone levels, incr. risk of QT prolongation, cardiac arrhythmias, other adverse effects (hepatic metab. inhibited)

milnaciprancaution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake)

nevirapinecaution advised: combo may incr. nevirapine levels, risk of adverse effects (hepatic metab. inhibited)

NSAID/chlorpheniramine/pseudoephedrine comboscaution advised: combo w/ NSAIDs may incr. risk of bleeding (additive effects)[NSAID/chlorpheniramine/pseudoephedrine combos: ibuprofen/chlorpheniramine/pseudoephedrine]

NSAID/diphenhydramine comboscaution advised: combo w/ NSAIDs may incr. risk of bleeding (additive effects)[NSAID/diphenhydramine combos: ibuprofen/diphenhydramine]

NSAID/phenylephrine comboscaution advised: combo w/ NSAIDs may incr. risk of bleeding (additive effects)[NSAID/phenylephrine combos: ibuprofen/phenylephrine]

NSAID/pseudoephedrine comboscaution advised: combo w/ NSAIDs may incr. risk of bleeding (additive effects)[NSAID/pseudoephedrine combos: ibuprofen/pseudoephedrine, naproxen sodium/pseudoephedrine]

NSAIDscaution advised: combo may incr. risk of bleeding (additive effects)[NSAIDs: diclofenac potassium, diclofenac sodium, diclofenac/misoprostol, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, ibuprofen lysine, indomethacin, ketoprofen, ketorolac, ketorolac nasal, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, naproxen sodium, oxaprozin, piroxicam, sulindac, tolmetin]

NSAIDs, ophthalmiccaution advised: combo may incr. ocular bleeding risk postop (additive effects)[NSAIDs, ophthalmic: bromfenac ophthalmic, diclofenac ophthalmic, flurbiprofen ophthalmic, ketorolac ophthalmic, nepafenac ophthalmic]

olanzapinecaution advised: combo may incr. olanzapine levels, risk of adverse effects (hepatic metab. inhibited)

omega-3-acidcaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[omega-3-acid: omega-3-acid ethyl esters]

oxycodone/ibuprofencaution advised: combo may incr. risk of bleeding (additive effects)

paroxetinecaution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake)

pentamidinecaution advised: combo may incr. pentamidine levels, risk of adverse effects, incl. QT prolongation, cardiac arrhythmias (hepatic metab. inhibited)

porfimercaution advised: combo may decr. efficacy of photodynamic tx; antiplatelet agents may decr. thromboxane A2-mediated tumor necrosis (antagonistic effects)

propofolcaution advised: combo may incr. propofol levels, risk CNS and respiratory depression, other adverse effects (hepatic metab. inhibited)[propofol: fospropofol, propofol]

propranololcaution advised: combo may incr. propranolol levels, risk of adverse effects (hepatic metab. inhibited)

selegilinecaution advised: combo may incr. selegiline levels, risk of adverse effects (hepatic metab. inhibited)

selegiline transdermalcaution advised: combo may incr. selegiline levels, risk of adverse effects (hepatic metab. inhibited)

sertralinecaution advised: combo may incr. risk of bleeding; may incr. SSRI levels, risk of adverse effects (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake; hepatic metab. inhibited)

sibutraminecaution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake)

sumatriptan/naproxen sodiumcaution advised: combo w/ NSAIDs may incr. risk of bleeding (additive effects)

thrombin inhibitorscaution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)[thrombin inhibitors: antithrombin (recombinant), antithrombin III, argatroban, dabigatran, lepirudin]

tramadolcaution advised: combo may incr. tramadol levels, risk of seizures, other adverse effects (hepatic metab. inhibited)

tramadol/acetaminophencaution advised: combo may incr. tramadol levels, risk of seizures, other adverse effects (hepatic metab. inhibited)

trazodonecaution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake)

treprostinilcaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[treprostinil: treprostinil, treprostinil inhaled]

valproic acid derivativescaution advised: combo may incr. risk of bleeding (additive antiplatelet effects)[valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid]

vardenafilcaution advised: combo may incr. vardenafil levels, risk of adverse effects (hepatic metab. inhibited)

venlafaxinecaution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake)

verteporfincaution advised: combo may decr. verteporfin efficacy (mechanism unknown)

vilazodonecaution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake)

willow barkcaution advised: combo may incr. risk of bleeding, adverse effects (additive effects, willow bark may contain salicylates)[willow bark: basket willow, bay willow, brittle willow, osier rouge, purple osier, salicis cortex, Salix alba, Salix fragilis, Salix pentandra, Salix purpurea, violet willow, white willow, willow bark (Salix spp.)]

Adverse Reactions

Serious Reactions

bleeding, severe hemorrhage

TTP

agranulocytosis

hypersensitivity rxn

anaphylactoid rxns

Stevens-Johnson syndrome

toxic epidermal necrolysis

erythema multiforme

Common Reactions

bleeding pruritus

Safety/Monitoring

Pregnancy: B (Animal studies show no risk or adverse fetal effects but controlled human 1st trimester studies not avail/do not confirm; no evidence of 2nd or 3rd trimester risk; fetal harm possible but unlikely; see pkg insert drug-specific recs)

Lactation: Safety Unknown (Inadequate literature available to assess risk; caution advised)

Monitoring Parameters no routine tests recommended

Pharmacology

Metabolism: liver; CYP450: 1A2, 2C9, 2C19 (primary), 3A4 substrate; 2B6, 2C9/19 inhibitor; Info: prodrug converted to active thiol derivative

Excretion: urine 50%, feces 46%; Half-life: 8h

Subclass: Antiplatelets; Stroke

Mechanism of Actionirreversibly binds to P2Y12 adenosine diphosphate receptors, reducing platelet activation and aggregation

Manufacturer/Pricing

Manufacturer: generic

DEA/FDA: Rx: (Requires prescription; not a controlled substance)

Approximate Retail Price

from  www.drugstore.com

This information is currently not available for this drug.

Patient Education

Nombre Genérico: clopidogrel

Nombre de la Marca: Plavix

¿Cuál es la información más importante que debo saber sobre clopidogrel?

Clopidogrel hace que su sangre no forme coágulos para evitar los indeseados coágulos de la sangre que pueden ocurrir con ciertas condiciones del corazón o de los vasos sanguíneos. A consecuencia de esta acción de la droga, clopidogrel puede hacer fácil a que sangre, aun cuando el corte es mínimo. Hable con su médico o busque atención medica de emergencia si tiene sangramiento que no lo puede parar.

Usted también puede tener sangramiento dentro del cuerpo, así como en su estómago o intestinos. Hable de inmediato con su médico si tiene heces fecales negras o con sangre, o si la tos tiene sangre o el vómito tiene la apariencia de café molido. Estos pueden ser síntomas de sangramiento en su tracto digestivo.

Evite beber alcohol. Le puede aumentar su riesgo de sangramiento en su estómago o intestinos.

Si necesite cirugía o procedimiento dental, informe a los cirujanos o dentistas en adelantado que usted está usando clopidogrel. Tal vez necesite dejar de usar la medicina por lo menos 5 días antes de tener una cirugía para evitar sangrar en exceso. Siga las instrucciones de su médico y empiece a tomar clopidogrel otra vez tan pronto sea posible.

Mientras esté tomando clopidogrel, no tome aspirin u otro AINE (anti-inflamatorio no esteroide (NSAIDs, por sus siglas en Inglés)) sin la aprobación de su médico. Los AINEs (NSAIDs) incluyen ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn, Naprelan, Treximet), celecoxib (Celebrex), diclofenac (Cataflam, Voltaren), indomethacin (Indocin), meloxicam (Mobic), y otras.

Dígale a su médico acerca de todas las medicinas que usted use para prevenir los coágulos sanguíneos.

¿Qué es clopidogrel?

Clopidogrel previene la acumulación (formación de coágulo) de las plaquetas en la sangre. Esto evita que se formen coágulos sanguíneos que pueden ocurrir con ciertas condiciones cardiacas o de los vasos sanguíneos..

Clopidogrel se usa en la prevención de coágulos sanguíneos después de un reciente ataque cardiaco o accidente cerebrovascular, y en las personas con problemas del corazón o de los vasos sanguíneos.

Clopidogrel puede usarse también para fines distintos a los que se señalan en esta guía del medicamento.

¿Qué debería discutir con el profesional de la salud antes de tomar clopidogrel?

No use esta medicina si tiene alergia a clopidogrel, o si tiene sangrado activo como úlcera del estómago o sangramiento en el cerebro (de una herida a la cabeza).

Si usted tiene cualquiera de estas otras condiciones, usted quizás necesite modificar su dosis o pruebas especiales:

problema de sangramiento o de coágulos de sangre, como TTP (púrpura trombocitopénica trombótica) o hemofilia;

historia de accidente cerebrovascular, que incluye TIA ("mini-stroke");

úlcera del estómago o colitis ulcerativa; o

enfermedad del riñón.

Clasificado por la FDA en la categoría B de Riesgos a la Gestación. No se anticipa que esta medicina le haga daño al bebé nonato. Dígale a su médico si usted está embarazada o planea un embarazo durante su tratamiento.

No se sabe si clopidogrel pasa a la leche materna o si le puede hacer daño al bebé que está mamando. No use esta medicina sin consultar antes con su médico si está dando de amamantar al bebé.

¿Cómo debo tomar clopidogrel?

Tómelo exactamente cómo lo haya recetado su médico. No lo tome en cantidades mayores o menores, o por más tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripción.

Tome esta medicina con un vaso de agua lleno.

Clopidogrel puede tomarse con o sin comida.

Ya que clopidogrel hace que su sangre no se coagulé (coágulos) para evitar coágulos de sangre no deseados, puede también hacer más fácil a que sangre, aun cuando la herida es pequeña. Hable con su médico o busque atención medica de emergencia si tiene sangramiento que no lo puede parar.

Si necesite cirugía o procedimiento dental, informe a los cirujanos o dentistas en adelantado que usted está usando clopidogrel. Tal vez necesite dejar de usar la medicina por lo menos 5 días

antes de tener una cirugía para evitar sangrar en exceso. Siga las instrucciones de su médico y empiece a tomar clopidogrel otra vez tan pronto sea posible.

No deje de usar clopidogrel sin primero hablar con su médico. Usar clopidogrel regularmente para obtener el mayor beneficio. Vuelva a llenar su prescripción antes de que se quede completamente sin medicina.

Para estar seguro de que esta medicina no le está haciendo daño, se necesitará examinar su sangre con frecuencia. Visite a su médico con regularidad.

Guarde a temperatura ambiente, lejos de la humedad y el calor.

¿Qué sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sáltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome más medicina para alcanzar la dosis pasada.

¿Qué sucedería en una sobredosis?

Busque atención médica de emergencia o llame a la línea de Poison Help al 1-800-222-1222.

Los síntomas de una sobredosis de clopidogrel pueden incluir vómito, sentirse muy cansado o que le falta aire al respirar y sangre en sus heces fecales o vómito.

¿Qué debo evitar mientras tomo clopidogrel?

Mientras esté tomando clopidogrel, no tome aspirin u otro AINE (anti-inflamatorio no esteroide (NSAIDs, por sus siglas en Ingles)) sin la aprobación de su médico. Los AINEs (NSAIDs) incluyen ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn, Naprelan, Treximet), celecoxib (Celebrex), diclofenac (Cataflam, Voltaren), indomethacin (Indocin), meloxicam (Mobic), oteros, y otras.

Evite actividades que pueden aumentar su riesgo de sangrado o herida. Use cuidados extras para prevenir el sangrado mientras se afeita o se lava los dientes.

Evite beber alcohol. Le puede aumentar su riesgo de sangramiento en su estómago o intestinos.

¿Cuáles son los efectos secundarios posibles de clopidogrel?

Busque atención médica de emergencia si tiene alguno de estos síntomas de una reacción alérgica: ronchas, dificultad para respirar, hinchazón de la cara, labios, lengua, o garganta.

Deje de usar clopidogrel y hable de inmediato con su médico si nota alguno de estos efectos secundarios de gravedad:

sangrar por la nariz u otro sangramiento que no para; heces fecales negras o con sangre, sangre en la orina;

toser sangre o vómito con apariencia a café molido;

dolor del pecho o sensación de peso, dolor que se reparte al brazo u hombro, náusea, sudor, sentirse enfermo;

entumecimiento súbito o debilidad, en particular a un lado del cuerpo;

dolor súbito de la cabeza, confusión, problemas con la visión, el hablar, o el balance;

piel pálida, debilidad, fiebre, o ictericia (color amarillo de la piel u ojos); o

moretones fácil, sangrado inusual (nariz, boca, vagina, o recto), manchas debajo de la piel en forma de puntos morados o rojos.

Efectos secundarios de menor gravedad pueden incluir picazón.

Esta lista no menciona todos los efectos secundarios y puede ser que ocurran otros. Llame a su médico para consejos médicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

¿Qué otras drogas afectarán a clopidogrel?

Dígale a su médico acerca de todas las medicinas que usted use para prevenir los coágulos sanguíneos, incluyendo:

abciximab (ReoPro); dalteparin (Fragmin);

enoxaparin (Lovenox);

eptifibatide (Integrilin);

fondaparinux (Arixtra);

heparin;

ticlopidine (Ticlid);

tinzaparin (Innohep);

tirofiban (Aggrastat);

urokinase (Abbokinase); y

warfarin (Coumadin, Jantoven).

Dígale a su médico acerca de todas las medicinas que usted use, especialmente:

armodafinil (Nuvigil) o modafinil (Provigil); fluoxetine (Prozac) o fluvoxamine (Luvox);

gemfibrozil (Lopid);

isoniazid (Rifamate, Rifater);

una medicina para el cáncer como dasatinib (Sprycel), letrozole (Femara), ibritumomab (Zevalin), o tositumomab (Bexxar);

algunos medicinas que se usan para reducir la cantidad de ácido en el estómago, como cimetidine (Tagamet), esomeprazole (Nexium), o omeprazole (Prilosec, Prilosec OTC, Zegerid);

una medicina antifúngica como fluconazole (Diflucan), ketoconazole (Nizoral), o voriconazole (Vfend);

medicamentos contra el VIH como delavirdine (Rescriptor), efavirenz (Sustiva, Atripla), etravirine (Intelence), o tipranavir (Aptivus); o

medicina para las convulsiones como felbamate (Felbatol) o oxcarbazepine (Trileptal).

Esta lista no incluye todas las drogas y pueden existir otras que tengan interacciones con clopidogrel. Dígale a su médico acerca de todas los medicamentos que usted use. Incluya los productos que se obtienen con o sin receta, vitaminas, y productos herbarios. No empiece a usar un medicamento nuevo sin primero decirle a su médico.

¿Dónde puedo obtener más información?

Su farmacéutico le puede dar más información sobre clopidogrel (Plavix).

Drug

nitroglyceringeneric

Entire Monograph

Adult Dosing

Dosage forms:  0.3,0.4,0.6 SL tab; 2.5,6.5,9 ER; IV

angina, acute

[0.3-0.6 mg SL q5min]Max: 3 doses w/in 15min; Alt: 5 mcg/min IV, incr. 5-20 mcg/min q3-5min; usual dose 5-200 mcg/min; Info: use IV if unresponsive to SL NTG and beta blockers

angina prophylaxis

[0.3-0.6 mg SL x1]Alt: 2.5-9 mg ER PO q8-12h; Info: use SL 5-10min before strenuous activity

HTN

[5-200 mcg/min IV]Start: 5 mcg/min IV and incr. 5 mcg/min q3-5min until response or 20 mcg/min; if no response then incr. 10-20 mcg/min q3-5min

CHF

[5-200 mcg/min IV]Start: 5 mcg/min IV and incr. 5 mcg/min q3-5min until response or 20 mcg/min; if no response then incr. 10-20 mcg/min q3-5min

renal dosing

[no adjustment]HD/PD: not defined

hepatic dosing

[not defined]

Peds Dosing

Dosage forms:  IV

*HTN

[1-5 mcg/kg/min IV]Start: 0.25-0.5 mcg/kg/min, incr. 0.5-1 mcg/kg/min q3-5min until response; Max: 20 mcg/kg/min

*CHF

[1-5 mcg/kg/min IV]Start: 0.25-0.5 mcg/kg/min, incr. 0.5-1 mcg/kg/min q3-5min until response; Max: 20 mcg/kg/min

renal dosing

[see Adult Dosing]

renal impairment: dose adjustment may be required although specific pediatric dosing adjustments not defined; see adult renal dosing for guidance

hepatic dosing

[not defined]

Contraindications/Cautions

hypersens. to drug/class/compon. pericardial tamponade (IV use)

cardiomyopathy, restrictive (IV use)

pericarditis, constrictive (IV use)

anemia, severe

ICP incr.

sildenafil use

methemoglobinemia

caution if hypovolemia

caution if hypotension

caution if IHSS

caution if acute MI

caution if CHF

caution if malabsorption (ER form)

caution if GI hypermotility (ER form)

caution if cerebral hemorrhage

caution if head injury

Drug Interactions

Contraindicated

sildenafilcontraindicated: combo may incr. risk of severe hypotension, cardiovascular collapse (synergistic effects)

tadalafilcontraindicated, allow 48h after last tadalafil dose before giving nitrates: combo may incr. risk of severe hypotension, cardiovascular collapse (synergistic effects)

vardenafilcontraindicated: combo may incr. risk of severe hypotension, tachycardia, cardiovascular collapse (synergistic effects)

Avoid/Use Alternative

ergot alkaloidsavoid combo, especially w/ dihydroergotamine (DHE): combo may decr. nitrate efficacy, incr. DHE levels; risk of vasoconstriction, angina, ischemia (antagonistic effects; DHE metab. altered by NTG)[ergot alkaloids: dihydroergotamine, dihydroergotamine nasal, methylergonovine]

ergotamine/caffeineavoid combo: combo may decr. nitrate efficacy; incr. risk of vasoconstriction, angina, ischemia observed w/ DHE (antagonistic effects; DHE metab. altered by NTG)

ethanolavoid or minimize alcohol use: combo may incr. risk of hypotension (additive effects)

local anestheticsavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)[local anesthetics: bupivacaine, bupivacaine liposomal, chloroprocaine, lidocaine, mepivacaine, procaine, ropivacaine]

local anesthetics/epinephrineavoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)[local anesthetics/epinephrine: articaine/epinephrine]

promethazine/codeineavoid combo or use alternative: combo w/ phenothiazines may incr. risk of hypotension (additive effects)

rosiglitazoneavoid combo: combo may incr. risk of myocardial ischemia (mechanism unknown)

rosiglitazone/glimepirideavoid combo: combo may incr. risk of myocardial ischemia (mechanism unknown)

rosiglitazone/metforminavoid combo: combo may incr. risk of myocardial ischemia (mechanism unknown)

Monitor/Modify Tx

amifostinecaution advised, monitor BP: combo may incr. risk of hypotension (additive effects)

amlodipine/ARB comboscaution advised, monitor BP: combo may incr. risk of hypotension (additive effects)[amlodipine/ARB combos: amlodipine/olmesartan, amlodipine/valsartan, telmisartan/amlodipine]

amlodipine/ARB/thiazide comboscaution advised, monitor BP: combo may incr. risk of hypotension (additive effects)[amlodipine/ARB/thiazide combos: amlodipine/valsartan/hydrochlorothiazide, olmesartan/amlodipine/hydrochlorothiazide]

asenapinemonitor BP: combo may incr. risk of hypotension (additive effects)

heparinmonitor aPTT: combo, esp. with IV nitroglycerin, may decr. anticoagulant efficacy of heparin (mechanism unknown)

iloperidonemonitor BP: combo may incr. risk of hypotension (additive effects)

isosorbide dinitrate/hydralazinemonitor BP: combo may incr. risk of hypotension (additive effects, duplicate nitrate tx)

nesiritidemonitor BP: combo may incr. risk of hypotension (additive/synergistic effects)

Caution Advised

aldesleukincaution advised: combo may incr. risk of hypotension (additive effects)

alfuzosincaution advised: combo may incr. risk of hypotension, syncope (additive effects)

aliskiren/amlodipinecaution advised: combo may incr. risk of orthostatic hypotension (additive effects)

aliskiren/amlodipine/hydrochlorothiazidecaution advised: combo may incr. risk of orthostatic hypotension (additive effects)

alteplasecaution advised w/ IV, SL nitroglycerin: combo w/ IV nitroglycerin may decr. thrombolytic efficacy of alteplase; similar effect possible w/ SL nitroglycerin (mechanism unknown)

amlodipine/atorvastatincaution advised: combo may incr. risk of hypotension (additive effects)

anticholinergicscaution advised w/ SL nitroglycerin: anticholinergics may decr. salivary secretions and dissolution of SL tablets (absorption decreased)[anticholinergics: amantadine, atropine, benztropine, chlordiazepoxide/clidinium, dicyclomine, difenoxin/atropine, diphenoxylate/atropine, fesoterodine, flavoxate, glycopyrrolate, hyoscyamine, methscopolamine, oxybutynin, oxybutynin topical, oxybutynin transdermal, propantheline, scopolamine, scopolamine transdermal, tolterodine, trihexyphenidyl, trospium]

apomorphinecaution advised: combo may incr. risk of orthostatic hypotension, MI, pneumonia, falls, other apomorphine adverse effects (additive effects)

benzocainecontraindicated if <1 yo, otherwise caution advised: combo w/ benzocaine may incr. risk of methemoglobinemia (additive effects)[benzocaine: benzalkonium chloride/benzocaine/zinc chloride oropharyngeal, benzethonium chloride/benzocaine topical, benzocaine oropharyngeal, benzocaine topical, benzocaine/allantoin/dimethicone/petrolatum topical, benzocaine/butamben/tetracaine topical, benzocaine/camphor/allantoin/dimethicone/petrolatum topical, benzocaine/camphor/allantoin/petrolatum topical, benzocaine/camphor/menthol/allantoin/dimethicone/petrolatum topical, benzocaine/glycerin oropharyngeal, benzocaine/menthol oropharyngeal, benzocaine/menthol topical, benzocaine/pectin oropharyngeal, benzocaine/petrolatum topical, benzocaine/zinc chloride oropharyngeal]

benzocaine/dextromethorphan comboscontraindicated if <1 yo, otherwise caution advised: combo w/ benzocaine may incr. risk of methemoglobinemia (additive effects)[benzocaine/dextromethorphan combos: benzocaine/dextromethorphan oropharyngeal, benzocaine/menthol/dextromethorphan oropharyngeal]

calcium channel blockers, dihydropyridinescaution advised: combo may incr. risk of hypotension (additive effects)[calcium channel blockers, dihydropyridines: amlodipine, amlodipine/benazepril, felodipine, isradipine, nicardipine, nifedipine, nimodipine, nisoldipine]

clevidipinecaution advised: combo may incr. risk of hypotension (additive effects)

darifenacincaution advised w/ SL nitroglycerin: anticholinergics may decr. salivary secretions and dissolution of SL tablets (absorption decreased)

diltiazemcaution advised: combo may incr. risk of hypotension (additive effects)

disopyramidecaution advised w/ SL nitroglycerin: disopyramide may decr. salivary secretions and dissolution of SL tablets (absorption decreased)

hawthorncaution advised: combo may result in excessive coronary vasodilation (additive vasodilatory effects)[hawthorn: aubepine, Chinese hawthorn, Crataegus laevigata, Crataegus monogyna, Crataegus oxyacantha, Crataegus pentagyna, English hawthorn, hawthorn (Crataegus spp.), hedgethorn, maybush, maythorn, oneseed hawthorn, shanzha, whitehorn]

iloprost inhaledcaution advised: combo may incr. risk of hypotension (additive/synergistic effects)

lidocaine topicalcontraindicated if <1 yo, otherwise caution advised: combo w/ topical lidocaine may incr. risk of methemoglobinemia (additive effects)[lidocaine topical: benzethonium chloride/lidocaine topical, hydrocortisone/lidocaine topical, lidocaine oronasopharyngeal, lidocaine topical, lidocaine urethral, lidocaine/epinephrine iontophoretic topical, lidocaine/prilocaine topical, lidocaine/tetracaine topical]

maraviroccaution advised: combo may incr. risk of orthostatic hypotension (additive effects)

niacincaution advised: combo may incr. risk of orthostatic hypotension (additive effects)

niacin/lovastatincaution advised: combo w/ niacin may incr. risk of orthostatic hypotension (additive effects)

niacin/simvastatincaution advised: combo w/ niacin may incr. risk of orthostatic hypotension (additive effects)

nitrites/sodium thiosulfatecaution advised: combo may incr. risk of methemoglobinemia, hypotension (additive effects)[nitrites/sodium thiosulfate: amyl nitrite/sodium nitrite/sodium thiosulfate, sodium nitrite/sodium thiosulfate]

nitroprussidecaution advised: combo may incr. risk of methemoglobinemia (additive effects)

phenobarbital/hyoscyamine/atropine/scopolaminecaution advised w/ SL nitroglycerin: anticholinergics may decr. salivary secretions and dissolution of SL tablets (absorption decreased)

phenothiazinescaution advised: combo may incr. risk of hypotension (additive effects)[phenothiazines: chlorpromazine, fluphenazine, fluphenazine decanoate, perphenazine, prochlorperazine edisylate, prochlorperazine maleate, prochlorperazine rectal, promethazine, promethazine rectal, thioridazine, trifluoperazine]

silodosincaution advised: combo may incr. risk of hypotension, syncope (additive effects)

solifenacincaution advised w/ SL nitroglycerin: anticholinergics may decr. salivary secretions and dissolution of SL tablets (absorption decreased)

treprostinilcaution advised: combo may incr. risk of symptomatic hypotension (additive effects)[treprostinil: treprostinil, treprostinil inhaled]

tricyclic antidepressantscaution advised w/ SL nitroglycerin: TCAs may decr. salivary secretions and dissolution of SL tablets (absorption decreased)[tricyclic antidepressants: amitriptyline, amoxapine, chlordiazepoxide/amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, perphenazine/amitriptyline, protriptyline, trimipramine]

verapamilscaution advised: combo may incr. risk of hypotension (additive effects)[verapamils: trandolapril/verapamil, verapamil]

Adverse Reactions

Serious Reactions

hypotension, severe nitrate tolerance (excessive or continuous use)

bradycardia, paradoxical

anaphylactoid rxns

methemoglobinemia

Common Reactions

headache lightheadedness

dizziness

flushing

hypotension, orthostatic

reflex tachycardia

edema

burning oral sensation (SL use)

tingling oral sensation (SL use)

Safety/Monitoring

Pregnancy: C (Animal studies show adverse fetal effect(s) but no controlled human studies OR no animal or human studies; weigh possible fetal risk vs. maternal benefit; see pkg insert for drug-specific recs)

Lactation: Safety Unknown (Inadequate literature available to assess risk; caution advised)

Monitoring Parameters BP

Look/Sound-Alike Drug Names [from www.usp.org]

nitroglycerin confused with: glycerin; Neo-Synephrine; nicotine; nitrofurantoin; nitroprusside; nystatin

Pharmacology

Metabolism: liver, erythrocytes, vascular walls; CYP450: unknown; Info: active metabolites

Excretion: urine; Half-life: 1-3min, 40min (metabolites)

Subclass: Vasodilators/Nitrates

Mechanism of Actionstimulates cGMP production, resulting in vascular smooth muscle relaxation

Manufacturer/Pricing

Manufacturer: generic

DEA/FDA: Rx: (Requires prescription; not a controlled substance)

Approximate Retail Price

from  www.drugstore.com

capsule, extended release:

2.5 mg (30 ea): $19.99 6.5 mg (30 ea): $22.99

9 mg (30 ea): $34.99

Patient Education

Nombre Genérico: nitroglycerin (oral/sublingual)

Nombres de las Marcas: Nitro-Time, Nitrolingual, Nitrolingual Duo Pack, Nitromist, Nitrostat

¿Cuál es la información más importante que debo saber sobre nitroglycerin?

No use nitroglycerin si usted está tomando sildenafil (Viagra, Revatio), tadalafil (Cialis), o vardenafil (Levitra). Efectos secundarios graves, que ponen su vida en peligro, pueden ocurrir si toma nitroglycerin mientras esté usando sildenafil.

Nitroglycerin puede causar dolor de cabeza agudo, en particular cuando empiece a usarlo. Estos dolores de cabeza con el tiempo dejan de ser tan agudos a medida que sigue usando la medicina. No deje de tomar nitroglycerin. Pregúntele a su médico antes usar alguna medicina para el dolor de cabeza.

¿Qué es nitroglycerin?

Nitroglycerin miembro del grupo de drogas denominadas nitratos. Nitroglycerin dilata (ensancha) los vasos sanguíneos, haciendo más fácil para que el flujo de sangre pase a través de estos y para que el corazón pueda bombear con más facilidad.

Nitroglycerin se usa para el tratamiento o prevención del ataque de dolor al pecho (angina).

Nitroglycerin puede también usarse para fines no mencionados en esta guía del medicamento.

¿Qué debería discutir con el profesional de la salud antes de tomar nitroglycerin?

No use nitroglycerin si usted está tomando sildenafil (Viagra, Revatio), tadalafil (Cialis), o vardenafil (Levitra). Efectos secundarios graves, que ponen su vida en peligro, pueden ocurrir si toma nitroglycerin mientras esté usando sildenafil.

No use esta medicina sin el consejo de su médico si usted tiene síntomas tempranos de un ataque al corazón (dolor del pecho o pesadez en el pecho, dolor que se extiende al brazo u hombro, náusea, sudor, sentirse enfermo). Busque atención médica de emergencia si usted tiene síntomas de ataque al corazón.

No use esta medicina si usted es alérgico a nitroglycerin u otros nitratos como isosorbide dinitrate (Dilatrate, Isordil, Isochron) o isosorbide mononitrate (Imdur, ISMO, Monoket), o si usted tiene:

anemia aguda (nivel bajo de las células rojas de la sangre); o una herida en el cerebro, hemorragia, o tumor.

Para asegurarse que usted puede tomar nitroglycerin de forma segura, dígale a su médico si usted tiene cualquiera de estas otras condiciones:

fallo cardiaco congestivo; historial de ataque al corazón, de accidente cerebrovascular, o herida en la cabeza;

presión arterial baja;

glaucoma;

migrañas; o

enfermedad del hígado.

Categoría C del embarazo por la FDA. No se conoce si nitroglycerin causará daño al bebé nonato. Dígale a su médico si usted está embarazada o planea quedar embarazada mientras está usando este medicamento.

No se sabe si la nitroglycerin pasa a la leche materna. No tome nitroglycerin sin antes consultar con su médico si está dando de amamantar al bebé.

Nitroglycerin puede causar dolor de cabeza agudo, en particular cuando empiece a usarlo. Estos dolores de cabeza con el tiempo dejan de ser tan agudos a medida que sigue usando la medicina. No deje de tomar nitroglycerin. Pregúntele a su médico antes usar alguna medicina para el dolor de cabeza.

¿Cómo debo tomar nitroglycerin

Tómelo exactamente como lo haya recetado su médico. No lo tome en cantidades mayores o menores, o por más tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripción.

Si puede, trate de descansar o mantenerse sentado cuando use esta medicina. Nitroglycerin puede causar mareo o desmayo.

Si usa nitroglycerin sublingual aerosol para el tratamiento de un ataque de angina: A la primera señal de un ataque, rocíe el aerosol sobre o debajo de su lengua. Cierre su boca después de cada aerosol. No inhale la nebulización. No agite el aerosol antes o durante su uso. Usted tal vez use el aerosol varias veces cada 5 minutos, pero no use más de 3 nebulizaciones en 15 minutos.

Usted puede usar el aerosol de nitroglicerina dentro de 5 a 10 minutos antes de hacer una actividad que pueda causarle dolor de pecho. Siga las instrucciones de su médico.

Coloque la nitroglycerin tableta sublingual debajo de su lengua y deje que se disuelva de forma lenta. No la mastique o la trague. Usted tal vez use las tabletas varias veces cada 5 minutos, pero no use más de 3 tabletas en 15 minutos.

Busque atención médica de emergencia si su dolor del pecho empeora o dura más de 5 minutos, en particular si teme dificultad para respirar o se siente débil, mareado, con náuseas, o siente que se puede desmayar.

Usted puede tener una sensación leve quemante o punzante en su boca cuando use esta medicina. Sin embargo, esta sensación no es una señal de que tan bien la medicina está trabajando. No use mas medicina solo porque usted no siente la sensación quemante o punzante.

No triture, mastique, rompo, o abra una cápsula de liberación extendida. Trague la pastilla entera. Ha sido preparada de forma especial para que entregue la medicina lentamente al cuerpo. Romperla o abrirla podría hacer que demasiada medicina pasa al cuerpo de forma rápida.

Este medicamento puede causar resultados inusuales con ciertas pruebas médicas. Dígale a cualquier médico que lo atiende que usted está usando nitroglycerin.

Mantenga esta medicina a la mano todo el tiempo en caso de ataque de angina. Vuelva a llenar su prescripción antes de que se quede sin medicina.

Si usted toma nitroglycerin a horario regular para prevenir la angina, no la deje de tomar de forma súbita ya que podría tener un ataque de angina grave.

Guarde las tabletas de nitroglycerin en el envase de vidrio a temperatura ambiente fuera de la humedad y del calor. Mantenga la aerosol lejos de un llama abierta o calentura alta, como dejarlo dentro de un automóvil un día caluroso. El envase puede explotar se si calienta mucho.

¿Qué sucede si me salto una dosis?

Ya que nitroglycerin se toma cuando se necesita, usted tal vez no esté en un horario de dosis. Si usted está tomando el medicamento con regularidad, tome la dosis pasada tan pronto se acuerde. Sáltese la dosis pasada si su siguiente dosis la tiene que tomar en menos de 2 horas. No tome más medicina para alcanzar la dosis pasada.

¿Qué sucedería en una sobredosis?

Busque atención médica de emergencia o llame a la línea de Poison Help al 1-800-222-1222. Una sobredosis de nitroglycerin puede ser fatal.

Los síntomas de una sobredosis pueden incluir cefalea pulsátil aguda, latidos cardíacos rápidos o fuertes, mareo, problemas de la visión, náusea, vómito, diarrea con sangre, dificultad al respirar, piel fría o pegajosa, sentir que se puede desmayar, desmayo, y convulsiones.

¿Qué debo evitar mientras tomo nitroglycerin?

Nitroglycerin puede causar efectos que perjudiquen su pensar o reacciones. Tenga cuidado si usted conduce un vehículo o tenga que hacer algo que demande se mantenga despierto y alerta.

Evite consumir alcohol. Éste puede aumentar algunos de los efectos secundarios de nitroglycerin, como mareo, somnolencia, sentir que se puede desmayar, o desmayo.

¿Cuáles son los efectos secundarios posibles de la nitroglycerin?

Busque atención médica de emergencia si nota alguno de estos síntomas de una reacción alérgica: ronchas, dificultad para respirar; hinchazón de la cara, labios, lengua, o garganta.

Llame a su médico de inmediato si usted tiene un efecto secundario grave como:

paso cardíaco rápido, lento, fuerte, o desigual; visión borrosa o boca seca;

náusea, vómito, sudor, piel pálida, sentir que se puede desmayar; o

fiebre, dolor de garganta, y dolor de cabeza con una intensa presentación en la piel de ampollas, pelarse, y sarpullido rojo.

Efectos secundarios de menor gravedad pueden incluir:

quemazón leve, sensación de cosquilleo con la tableta en su boca; calentura, rojez, o cosquilleo debajo de la piel; o

debilidad o mareo.

Esta lista no menciona todos los efectos secundarios y puede ser que ocurran otros. Llame a su médico para consejos médicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

¿Qué otras drogas afectarán a la nitroglycerin?

Varias drogas pueden tener interacciones con nitroglycerin. La lista que se presenta abajo no incluye todas las drogas. Dígale a su médico si usted está usando:

alteplase (Activase); aspirin o heparin;

medicina para la vejiga o el sistema urinario como oxybutynin (Ditropan) o tolterodine (Detrol);

medicina para la presión arterial;

broncodilatadores como ipratropium (Atrovent) o tiotropium (Spiriva);

dihydroergotamine (D.H.E. 45, Migranal) o ergotamine (Ergomar, Cafergot, y otras);

un antidepresivo como amitriptyline (Elavil, Vanatrip, Limbitrol), clomipramine (Anafranil), imipramine (Tofranil), y otras;

una betabloqueantes como atenolol (Tenormin), carvedilol (Coreg), metoprolol (Lopressor, Toprol), nadolol (Corgard), propranolol (Inderal), sotalol (Betapace), y otras;

un bloqueantes del canal de calcio como diltiazem (Tiazac, Cardizem), nifedipine (Procardia), nimodipine (Nimotop), verapamil (Calan, Covera, Verelan), y otras;

medicinas para el intestino irritable como dicyclomine (Bentyl), hyoscyamine (Anaspaz, Cystospaz, y otras), o propantheline (Pro-Banthine);

cualquier medicina que la cause tener la boca seca; o

medicinas para el tratamiento de problemas psiquiátricos, como chlorpromazine (Thorazine), haloperidol (Haldol), thioridazine (Mellaril), y otras.

Esta lista no incluye todas las drogas y pueden haber varias medicinas que tengan interacciones con nitroglycerin. Dígale a su médico acerca de todas los medicamentos que usted use. Incluya los productos que se obtienen con o sin receta, vitaminas, y productos herbarios. No empiece a usar un medicamento nuevo sin primero decirle a su médico.

¿Dónde puedo obtener más información?

Su farmacéutico le puede dar más información acerca de nitroglycerin.

Drug

bisacodylgeneric

Entire Monograph

Adult Dosing

Dosage forms:  5 DR

constipation

[5-15 mg PO qd]Max: 30 mg/day; Info: do not cut/crush/chew tabs; avoid use w/in 1h of antacids or milk; do not use >1wk

bowel prep

[20 mg x1]

Max: 30 mg/day; Info: give >6h prior to desired effect; clear liquid diet on prep day to decr. cramping; effect onset 1-6h; begin bowel prep solution, if indicated, after 1st BM; do not cut/crush/chew tabs; avoid use w/in 1h of antacids or milk

renal dosing

[no adjustment]HD: not defined

hepatic dosing

[not defined]

Peds Dosing

Dosage forms:  5 DR

constipation

[3-12 yo]Dose: 5-10 mg PO qd; Max: 30 mg/day; Alt: 0.3 mg/kg PO qd; Info: do not cut/crush/chew tabs; avoid use w/in 1h of antacids or milk; do not use >1wk

[>12 yo]Dose: 5-15 mg PO qd; Max: 30 mg/day; Info: do not cut/crush/chew tabs; avoid use w/in 1h of antacids or milk; do not use >1wk

renal dosing

[no adjustment]HD: not defined

hepatic dosing

[not defined]

Contraindications/Cautions

hypersens. to drug/class/compon. acute abdomen

abdominal pain, undiagnosed

undiagnosed nausea/vomiting

GI obstruction or ileus

GI perforation

toxic megacolon

gastroenteritis

rectal bleeding

appendicitis

caution if inflammatory bowel dz

Drug Interactions

Avoid/Use Alternative

sodium phosphate, oralavoid combo: combo may incr. risk of dehydration, electrolyte abnormalities (additive effects)[sodium phosphate, oral: sodium phosphate]

Monitor/Modify Tx

antacidsseparate admin. by 1h: combo may result in premature dissolution of enteric-coating and incr. risk of GI cramps, adverse effects (absorption altered)[antacids: aluminum hydroxide, aluminum hydroxide/magnesium carbonate, aluminum hydroxide/magnesium hydroxide, aluminum hydroxide/magnesium hydroxide/simethicone, aluminum hydroxide/magnesium trisilicate, magnesium hydroxide]

calcium carbonate/magnesium hydroxideseparate admin. by 1h: combo may result in premature dissolution of enteric-coating and incr. risk of GI cramps, adverse effects (absorption altered)[calcium carbonate/magnesium hydroxide: calcium carbonate/magnesium hydroxide, calcium carbonate/magnesium hydroxide/simethicone]

didanosinecaution advised w/ antacid-buffered didanosine formulations, separate admin. by at least 1h: combo may result in premature dissolution of enteric-coating and incr. risk of GI cramps, adverse effects (absorption altered)

famotidine/calcium carbonate/magnesium hydroxideseparate admin. by 1h: combo may result in premature dissolution of enteric-coating and incr. risk of GI cramps, adverse effects (absorption altered)

magnesium hydroxide/mineral oilseparate admin. by 1h: combo w/ antacids may result in premature dissolution of enteric-coating and incr. risk of GI cramps, adverse effects (absorption altered)

Caution Advised

sodium sulfate/potassium sulfate/magnesium sulfatecaution advised: combo may incr. risk of colonic ulcers, ischemic colitis (additive effects)

Adverse Reactions

Serious Reactions

electrolyte imbalance (long-term use) cathartic colon (long-term use)

Common Reactions

nausea abdominal cramps

vomiting

rectal sensation burning

diarrhea

Safety/Monitoring

Pregnancy: C (Animal studies show adverse fetal effect(s) but no controlled human studies OR no animal or human studies; weigh possible fetal risk vs. maternal benefit; see pkg insert for drug-specific recs)

Lactation: Safety Unknown (Inadequate literature available to assess risk; caution advised)

Monitoring Parameters electrolytes if long-term tx

Look/Sound-Alike Drug Names [from www.usp.org]

bisacodyl confused with: bisoprolol; Visicol

Pharmacology

Metabolism: liver; CYP450: unknown; Info: 15% systemic absorption

Excretion: feces primarily, urine; Half-life: unknown

Subclass: Bowel Preps; Constipation

Mechanism of Actionincreases peristalsis (stimulant laxative)

Manufacturer/Pricing

Manufacturer: generic

DEA/FDA: OTC: (Available over-the-counter without prescription)

Approximate Retail Price

from  www.drugstore.com

This information is currently not available for this drug.

Patient Education

Nombre Genérico: bisacodyl

Nombres de las Marcas: Alophen, Bisac-Evac, Bisco-Lax, Carters Little Pills, Correctol, Doxidan Tablet, Dulcolax Laxative, Evac-U-Gen, Ex-lax Ultra, Feen-A-Mint, Fleet Bisacodyl, Gen Lax, Gentlax Tablet, Gentle Laxative, Laxative Gentle Suppositories, Magic Bullet, Modane, Veracolate

¿Cuál es la información más importante que debo saber sobre bisacodyl?

No use bisacodyl si tiene dolor de estómago (abdomen), náusea, o vómito, salvo que su médico le indique diferente.

Si usted nota un cambio súbito en su funcionamiento de evacuación de sus intestinos que persisten por un periodo mayor de 2 semanas, hable con el profesional de la salud que lo atiende antes de usar un laxante.

Los productos de Bisacodyl no deben ser usados por más de una semana, a menos que el profesional de la salud que lo atiende le indique diferente.

El sangramiento por el recto o no poder tener una evacuación del intestino después de usar un laxante puede señalar que existe algo más grave. Deje de usar bisacodyl y comuniquese con el profesional de la salud que lo atiende.

¿Qué es bisacodyl?

Bisacodyl es un laxante estimulante. Éste causa que los músculos del colon se contraigan y dejen pasar a la heces fecales.

Bisacodyl se usa en el tratamiento del estreñimiento y para la evacuación del colon.

Bisacodyl también puede tener otros usos diferentes a los mencionados en está guía del producto.

¿Qué debería discutir con el profesional de la salud antes de tomar bisacodyl?

No tome bisacodyl sin antes hablar con su médico si tiene dolor abdominal (estómago), náusea, o vómito. Quizás no pueda tomar bisacodyl o tal vez necesite control especial.

Si usted nota un cambio súbito en su funcionamiento de evacuación de sus intestinos que persisten por un periodo mayor de 2 semanas, hable con el profesional de la salud que lo atiende antes de usar un laxante.

No tome bisacodyl sin primero hablar con su médico si usted está embarazada.

No tome bisacodyl sin antes hablar con su médico si está dando de amamantar al bebé.

Algunas de las preparaciones de bisacodyl han sido formuladas para el uso en niños. Hable con el médico del niño antes de usar este producto para tratar a un niño.

¿Cómo debo usar bisacodyl?

Tome bisacodyl exactamente como lo indique su médico o como lo indiquen en el paquete. Si no entiende estas instrucciones, pídale a su farmacéutico, enfermera, o médico que se las expliquen.

Tome cada dosis con un vaso de agua lleno.

Trague las pastillas y las cápsulas enteras. No las mastique o las muela.

No tome las pastillas de bisacodyl dentro de una hora después de haber tomado un antiácido o leche.

Bisacodyl también se encuentra disponible en formar de supositorio para uso en el recto. Uso del supositorio para el recto:

Si el supositorio se siente suave, sostengalo (aún dentro de la envoltura) bajo agua fría por uno o dos minutos antes de usarlo.

Quítele la envoltura. Si le han dicho, humedezca el supositorio con agua o vaselina.

Acuestese en uno de sus lados y con el extremo de punta, empuje el supositorio dentro del recto para que no se salga.

Retenga el supositorio por 15 a 20 minutes. Si siente que el supositorio se quiere salir de inmediato, no lo ha puesto bien adentro y debe empujarlo más adentro en el recto.

Bisacodyl también se encuentra disponible en forma de enema para uso por el recto. Uso de la enema por el recto:

Agite la botella ligeramente para asegurarse de que la suspensión está mezclada. Separe la tapa protectora del la punta del aplicador. Sostenga la botella por el cuello para evitar que se salga la medicina.

Con suavidad empuje la punta dentro del recto, en la dirección del ombligo. Apriete la botella con consistencia para entregar todo el medicamento.

El enema de bisacodyl por lo general produce evacuación intestinal dentro de 15 a 20 minutos. El supositorio de bisacodyl generalmente produce la evacuación intestinal entre 15 minutos a una hora. Las pastillas de bisacodyl por lo general producen una evacuación intestinal entre 6 a 12 horas. No tome bisacodyl por más de una semana, salvo que su médico le indique diferente.

Guarde bisacodyl a temperatura ambiente lejos de la humedad y el calor.

¿Qué sucede si dejo de usar una dosis?

Tome la dosis que se olvido tan pronto se acuerde. Sin embargo, si ya es casi la hora para su siguiente dosis, espere y tome solamente la siguiente dosis regularmente programada. No tome doble dosis.

¿Qué sucede si uso una sobredosis?

Busque atención médica de emergencia.

Los síntomas de una sobredosis de bisacodyl no se conocen, pero pudiesen incluir náusea, vómito o dolor de estómago.

¿Qué debo evitar mientras uso bisacodyl?

No tome las pastillas de bisacodyl dentro de la hora después de haber tomado un antiácido o leche.

¿Cuáles son los efectos secundarios posibles de bisacodyl?

Si usted nota alguno de los siguientes efectos secundarios, poco comunes, pero de gravedad, deje de tomar bisacodyl y busque atención médica o llame de inmediato a su médico:

una reacción alérgica (dificultad al respirar; cierre de la garganta; hinchazón de los labios, lengua, o cara; o ronchas);

sangramiento por el recto;

dolor abdominal fuerte, náusea o vómito; o

no tiene evacuación intestinal.

Otros efectos secundarios de menor gravedad son más probables de ocurrir. Siga tomando bisacodyl y hable con su médico si siente

mareo; malestar abdominal (estómago);

calambres;

diarrea; o

náusea leve.

Efectos secundarios diferentes a los mencionados aquí también pueden ocurrir. Hable con su médico acerca de cualquier efecto secundario que le parezca inusual o le cause molestia. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

¿Qué otras drogas afectarán a bisacodyl?

Antes de tomar bisacodyl, dígale a su médico si usted está tomando cualquiera de las medicinas a seguir:

un antiácido o medicina para aliviar la acedía; o las medicinas para el estómago, cimetidine (Tagamet, Tagamet HB), nizatidine (Axid,

Axid AR), famotidine (Pepcid, Pepcid AC), ranitidine (Zantac, Zantac 75), omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), pantoprazole (Protonix), o rabeprazole (Aciphex).

Quizás usted no pueda tomar bisacodyl, o tal vez necesite una modificación en su dosis o un control especial si está tomando alguna de las medicinas mencionadas arriba.

Otras drogas diferentes a las mencionadas aquí también pueden tener interacciones con bisacodyl. Hable con su médico y farmacéutico antes de tomar cualquier medicina, ya sea recetada o no, incluyendo los productos herbarios.

¿Dónde puedo obtener más información?

Su farmacéutico tiene más información acerca de bisacodyl preparada para el uso de los profesionales de la salud que usted puede leer.

Drug

captoprilgeneric

Entire Monograph

Black Box Warnings

Pregnancy

fetal/neonatal morbidity/mortality may occur when drugs that act directly on the renin-angiotensin system are used in pregnancy; D/C drug as soon as possible once pregnancy detected

Adult Dosing

Dosage forms:  12.5,25,50,100

HTN

[25-50 mg PO bid-tid]Start: 12.5-25 mg PO bid-tid, incr. 12.5-25 mg/dose q1-2wk; Max: 450 mg/day; Info: use lower initial dose if on diuretics; consider adding diuretic if suboptimal response to 50 mg PO tid; give 1h before meals; decr. efficacy as monotherapy in black pts

CHF

[12.5-50 mg PO tid]Start: 6.25-12.5 mg PO tid; Max: 150 mg tid; Info: use lower initial dose if on diuretics; give 1h before meals

nephropathy, diabetic

[25 mg PO tid]

MI, acute

[12.5-50 mg PO tid]Start: 6.25 mg PO x1 on day 3 post-MI, titrate up as tolerated q3-7 days; Info: give 1h before meals

renal dosing

[adjust dose amount, frequency]CrCl 10-50: decr. dose 25%, give q12-18h; CrCl <10: decr. dose 50%, give q24h; HD/PD: no supplement

hepatic dosing

[not defined]

Peds Dosing

Dosage forms:  12.5,25,50,100

*HTN

[premature neonates]Dose: 0.1-0.4 mg/kg/day PO div q6-24h; Start: 0.01 mg/kg/dose; Max: 2 mg/kg/day; Info: decr. efficacy as monotherapy in black pts

[neonates]Dose: 0.1-0.4 mg/kg/day PO div q6-24h; Start: 0.05-0.1 mg/kg/dose; Max: 2 mg/kg/day; Info: decr. efficacy as monotherapy in black pts

[infants]Dose: 2.5-6 mg/kg/day PO div q6-12h; Start: 0.15-0.3 mg/kg/dose; Max: 6 mg/kg/day; Info: decr. efficacy as monotherapy in black pts

[children]Dose: 2.5-6 mg/kg/day PO div q6-12h; Start: 0.3-0.5 mg/kg/dose or 6.25-12.5 mg/dose; Max: 6 mg/kg/day; Info: decr. efficacy as monotherapy in black pts

[adolescents]Dose: 25-50 mg PO q6-8h; Start: 12.5-25 mg PO q8h, incr. 12.5-25 mg/dose q1-2wk; Max: 450 mg/day; Info: use lower initial dose if on diuretics; consider adding diuretic if suboptimal response to 50 mg PO q8h; decr. efficacy as monotherapy in black pts

*CHF

[premature neonates]Dose: 0.1-0.4 mg/kg/day PO div q6-24h; Start: 0.01 mg/kg/dose; Max: 2 mg/kg/day

[neonates]Dose: 0.1-0.4 mg/kg/day PO div q6-24h; Start: 0.05-0.1 mg/kg/dose; Max: 2 mg/kg/day

[infants]Dose: 2.5-6 mg/kg/day PO div q6-12h; Start: 0.15-0.3 mg/kg/dose; Max: 6 mg/kg/day

[children]Dose: 2.5-6 mg/kg/day PO div q6-12h; Start: 0.3-0.5 mg/kg/dose or 6.25-12.5 mg/dose; Max: 6 mg/kg/day

[adolescents]

Dose: 25-50 mg PO q6-8h; Start: 12.5-25 mg PO q8h, incr. 12.5-25 mg/dose q1-2wk; Max: 450 mg/day; Info: use lower initial dose if on diuretics; consider adding diuretic if suboptimal response to 50 mg PO q8h

renal dosing

[adjust dose amount]CrCl 10-50: decr. dose 25%; CrCl <10: decr. dose 50%; HD/PD: no supplement

hepatic dosing

[not defined]

Contraindications/Cautions

hypersens. to drug/class/compon. ACE inhibitor angioedema hx

angioedema, hereditary

angioedema, idiopathic

pregnancy

caution if renal artery stenosis

caution if renal impairment

caution if volume depletion

caution if hyponatremia

caution if hypotension

caution in elderly pts

caution in black pts

caution if severe CHF

caution if aortic stenosis

caution if hypertrophic cardiomyopathy

caution if CAD

caution if cerebrovascular dz

caution if collagen vascular dz

caution if dialysis w/ high-flux membranes

caution if LDL apheresis w/ dextran

caution if antigen desensitization tx

Drug Interactions

Contraindicated

aliskirencontraindicated in diabetic pts; avoid combo in mod-severe renal impairment; monitor BP, potassium, renal fxn: combo may incr. risk of renal impairment, hypotension, hyperkalemia (additive/synergistic effects)

aliskiren/amlodipinecontraindicated in diabetic pts; avoid combo in mod-severe renal impairment; monitor BP, potassium, renal fxn: combo may incr. risk of renal impairment, hypotension, hyperkalemia (additive/synergistic effects)

aliskiren/amlodipine/hydrochlorothiazidecontraindicated in diabetic pts; avoid combo in mod-severe renal impairment; monitor BP, potassium, renal fxn: combo may incr. risk of renal impairment, hypotension, hyperkalemia (additive/synergistic effects)

aliskiren/hydrochlorothiazidecontraindicated in diabetic pts; avoid combo in mod-severe renal impairment; monitor BP, potassium, renal fxn: combo may incr. risk of renal impairment, hypotension, hyperkalemia (additive/synergistic effects)

aliskiren/valsartancontraindicated in diabetic pts; avoid combo in mod-severe renal impairment; monitor BP, potassium, renal fxn: combo may incr. risk of renal impairment, hypotension, hyperkalemia (additive/synergistic effects)

Avoid/Use Alternative

ACE inhibitor/thiazide combosavoid duplicate therapy: combo may incr. ACE inhibitor effects (additive effects)[ACE inhibitor/thiazide combos: benazepril/hydrochlorothiazide, captopril/hydrochlorothiazide, enalapril/hydrochlorothiazide, fosinopril/hydrochlorothiazide, lisinopril/hydrochlorothiazide, moexipril/hydrochlorothiazide, quinapril/hydrochlorothiazide]

allopurinolcaution advised, use alternative: combo may incr. risk of severe hypersensitivity rxn (mechanism unknown)

ARB/thiazide combosavoid combo of telmisartan and ramipril; monitor BP, potassium, renal fxn w/ other ARBs and ACE inhibitors: combo may incr. risk of hypotension, hyperkalemia, renal dysfxn; combo of telmisartan and ramipril may incr. ramipril levels, risk of adverse effects (additive effects, dual blockade of renin-angiotensin-aldosterone system; mechanism unknown)[ARB/thiazide combos: azilsartan/chlorthalidone, candesartan/hydrochlorothiazide, eprosartan/hydrochlorothiazide, irbesartan/hydrochlorothiazide, losartan/hydrochlorothiazide, olmesartan/hydrochlorothiazide, telmisartan/hydrochlorothiazide, valsartan/hydrochlorothiazide]

ARBsavoid combo of telmisartan and ramipril; monitor BP, potassium, renal fxn w/ other ARBs and ACE inhibitors: combo may incr. risk of hypotension, hyperkalemia, renal dysfxn; combo of telmisartan and ramipril may incr. ramipril levels, risk of adverse effects (additive effects, dual blockade of renin-angiotensin-aldosterone system; mechanism unknown)[ARBs: azilsartan, candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan]

azathioprineuse alternative: combo may incr. risk of severe leukopenia, hematologic toxicity (mechanism unknown)

lithiumavoid combo or monitor levels closely: combo may incr. lithium levels, risk of toxicity (renal excretion decreased)

Monitor/Modify Tx

acetaminophen/aspirincaution advised w/ high-dose aspirin or salicylates; monitor BP: combo w/ aspirin may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention)

acetaminophen/aspirin/caffeinecaution advised w/ high-dose aspirin or salicylates; monitor BP: combo w/ aspirin may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention)

acetaminophen/magnesium salicylate/pamabromcaution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention)

amifostinecaution advised, monitor BP: combo may incr. risk of hypotension (additive effects)

amlodipine/ARB combosavoid combo of telmisartan and ramipril; monitor BP, potassium, renal fxn w/ other

ARBs and ACE inhibitors: combo may incr. risk of hypotension, hyperkalemia, renal dysfxn; combo of telmisartan and ramipril may incr. ramipril levels, risk of adverse effects (additive effects, dual blockade of renin-angiotensin-aldosterone system; mechanism unknown)[amlodipine/ARB combos: amlodipine/olmesartan, amlodipine/valsartan, telmisartan/amlodipine]

amlodipine/ARB/thiazide combosmonitor BP, potassium, renal fxn: combo may incr. risk of hypotension, hyperkalemia, renal dysfxn (additive effects, dual blockade of renin-angiotensin-aldosterone system)[amlodipine/ARB/thiazide combos: amlodipine/valsartan/hydrochlorothiazide, olmesartan/amlodipine/hydrochlorothiazide]

antacidsgive captopril 1h before or 4h after: combo may decr. captopril levels, efficacy (absorption decreased)[antacids: aluminum hydroxide, aluminum hydroxide/magnesium carbonate, aluminum hydroxide/magnesium hydroxide, aluminum hydroxide/magnesium hydroxide/simethicone, aluminum hydroxide/magnesium trisilicate, magnesium hydroxide]

antipsychoticsmonitor BP: combo may incr. risk of hypotension (additive effects)[antipsychotics: aripiprazole, asenapine, clozapine, haloperidol, haloperidol decanoate, haloperidol lactate, iloperidone, loxapine, lurasidone, olanzapine, paliperidone, paliperidone palmitate, quetiapine, risperidone, thiothixene, ziprasidone]

aprotininmonitor BP: combo may decr. ACE inhibitor efficacy (mechanism unknown, possible antagonistic effects)

aspirin/caffeinecaution advised w/ high-dose aspirin or salicylates; monitor BP: combo w/ aspirin may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention)

aspirin/calcium carbonategive captopril 1h before or 4h after; caution advised w/ high-dose aspirin or salicylates; monitor BP: combo w/ calcium carbonate may decr. captopril levels, efficacy; combo w/ aspirin may decr. antihypertensive efficacy (absorption decreased; inhibition of renal prostaglandins, sodium and fluid retention)

aspirin/chlorpheniramine/dextromethorphancaution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention)

aspirin/chlorpheniramine/dextromethorphan/phenylephrinecaution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention)

aspirin/chlorpheniramine/phenylephrinecaution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention)

aspirin/diphenhydraminecaution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention)

aspirin/doxylamine/dextromethorphan/phenylephrinecaution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention)

aspirin/phenylephrinecaution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention)

beta blocker/thiazide combosmonitor BP, use for therapeutic advantage: combo may incr. risk of hypotension (synergistic effects)[beta blocker/thiazide combos: atenolol/chlorthalidone, bisoprolol/hydrochlorothiazide, metoprolol succinate/hydrochlorothiazide, metoprolol tartrate/hydrochlorothiazide, nadolol/bendroflumethiazide, propranolol/hydrochlorothiazide]

bismuth subsalicylatecaution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention)

bismuth subsalicylate/metronidazole/tetracyclinecaution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (antagonistic effects; salicylate-induced inhibition of renal prostaglandins, sodium and fluid retention)

calcium carbonate/magnesium hydroxidegive captopril 1h before or 4h after: combo may decr. captopril levels, efficacy (absorption decreased)[calcium carbonate/magnesium hydroxide: calcium carbonate/magnesium hydroxide, calcium carbonate/magnesium hydroxide/simethicone]

celecoxibmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

CNS depressant/aspirin/caffeine comboscaution advised w/ high-dose aspirin or salicylates; monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy (inhibition of renal prostaglandins, sodium and fluid retention)[CNS depressant/aspirin/caffeine combos: butalbital/aspirin/caffeine, butalbital/aspirin/caffeine/codeine, dihydrocodeine/aspirin/caffeine]

cyclosporinemonitor potassium, renal fxn: combo may incr. risk of hyperkalemia, nephrotoxicity (additive effects)[cyclosporine: cyclosporine modified, cyclosporine non-modified]

diclofenac topicalmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects; up to 10% systemic absorption of diclofenac topical; minimal absorption w/ patch)[diclofenac topical: diclofenac epolamine topical, diclofenac topical]

didanosinegive captopril 1h before or 4h after antacid-buffered didanosine: combo may decr. captopril levels, efficacy (absorption decreased at higher gastric pH)

digoxindecr. digoxin dose 15-30% and monitor levels, toxicity: combo may incr. digoxin levels, risk of toxicity (P-glycoprotein inhibited)

diuretics, loopmonitor BP, use for therapeutic advantage: combo may incr. risk of hypotension (synergistic effects)[diuretics, loop: bumetanide, ethacrynic acid, furosemide, torsemide]

diuretics, potassium-sparingmonitor potassium: combo may incr. risk of hyperkalemia (additive effects)[diuretics, potassium-sparing: amiloride, spironolactone, triamterene]

diuretics, potassium-sparing/thiazide combosmonitor BP, potassium, use for therapeutic advantage: combo may incr. risk of hypotension, hyperkalemia (additive/synergistic effects)[diuretics, potassium-sparing/thiazide combos: amiloride/hydrochlorothiazide, spironolactone/hydrochlorothiazide, triamterene/hydrochlorothiazide]

diuretics, thiazidemonitor BP, use for therapeutic advantage: combo may incr. risk of hypotension (synergistic effects)[diuretics, thiazide: chlorothiazide, chlorthalidone, clonidine/chlorthalidone, hydralazine/hydrochlorothiazide, hydrochlorothiazide, indapamide, methyclothiazide, metolazone]

drospirenonemonitor potassium: combo w/ drospirenone may incr. risk of hyperkalemia (additive effects)[drospirenone: drospirenone/estradiol, drospirenone/ethinyl estradiol, drospirenone/ethinyl estradiol/levomefolate]

eplerenonecaution advised, monitor BP, potassium: combo may incr. risk of hypotension, hyperkalemia (additive effects)

exenatidecaution advised, monitor renal fxn: combo may incr. risk of nephrotoxicity (additive toxicity)

famotidine/calcium carbonate/magnesium hydroxidegive captopril 1h before or 4h after: combo may decr. captopril levels, efficacy (absorption decreased)

heparinmonitor potassium: combo may incr. risk of hyperkalemia, risk may be greater w/ chronic heparin tx (additive effects)

hydrocodone/ibuprofenmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

ibuprofen/famotidinemonitor BP, renal fxn: combo w/ ibuprofen may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

insulinsmonitor glucose: combo may potentiate insulin effects, incr. risk of hypoglycemia (mechanism unknown)[insulins: insulin aspart, insulin aspart protamine/insulin aspart, insulin detemir, insulin glargine, insulin glulisine, insulin lispro, insulin lispro protamine/insulin lispro, insulin NPH, insulin NPH/regular, insulin regular]

liraglutidecaution advised, monitor renal fxn: combo may incr. risk of nephrotoxicity (additive toxicity)

magnesium hydroxide/mineral oilgive captopril 1h before or 4h after: combo w/ antacids may decr. captopril levels, efficacy (absorption decreased)

magnesium saltsgive captopril 1h before or 4h after: combo may decr. captopril levels, efficacy (absorption decreased)[magnesium salts: magnesium citrate, magnesium gluconate, magnesium oxide, magnesium sulfate]

metformin/sulfonylurea combosmonitor glucose: combo may incr. risk of hypoglycemia (mechanism unknown, possibly incr. insulin sensitivity)[metformin/sulfonylurea combos: glipizide/metformin, glyburide/metformin]

naproxen/esomeprazolemonitor BP, renal fxn: combo w/ NSAIDs may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

nesiritidemonitor BP: combo may incr. risk of hypotension (additive/synergistic effects)

NSAID/chlorpheniramine/pseudoephedrine combosmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[NSAID/chlorpheniramine/pseudoephedrine combos: ibuprofen/chlorpheniramine/pseudoephedrine]

NSAID/diphenhydramine combosmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[NSAID/diphenhydramine combos: ibuprofen/diphenhydramine]

NSAID/phenylephrine combosmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[NSAID/phenylephrine combos: ibuprofen/phenylephrine]

NSAID/pseudoephedrine combosmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[NSAID/pseudoephedrine combos: ibuprofen/pseudoephedrine, naproxen sodium/pseudoephedrine]

NSAIDsmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)[NSAIDs: diclofenac potassium, diclofenac sodium, diclofenac/misoprostol, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, ibuprofen lysine, indomethacin, ketoprofen, ketorolac, ketorolac nasal, meclofenamate, mefenamic acid, meloxicam, nabumetone, naproxen, naproxen sodium, oxaprozin, piroxicam, sulindac, tolmetin]

oxycodone/ibuprofenmonitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects due to NSAID-induced inhibition of renal prostaglandins, sodium and fluid retention; additive effects)

peginterferon alfa 2acaution advised, monitor CBC: combo w/ ACE inhibitor may incr. risk of granulocytopenia, thrombocytopenia (mechanism unknown, possible autoimmune destruction of myeloid precursors)

polyethylene glycol/electrolytesmonitor electrolytes: combo may incr. risk of seizures (additive effects)

[polyethylene glycol/electrolytes: polyethylene glycol/electrolytes, polyethylene glycol/electrolytes and bisacodyl, polyethylene glycol/electrolytes/sodium ascorbate/ascorbic acid]

potassium bicarbonate/potassium citratemonitor potassium, check potassium content of supplement: combo may incr. risk of hyperkalemia (additive effects)

potassium saltsmonitor potassium, check potassium content of supplement: combo may incr. risk of hyperkalemia (additive effects)[potassium salts: potassium acid phosphate, potassium acid phosphate/sodium acid phosphate, potassium chloride, potassium citrate, potassium iodide, sodium phosphate/potassium phosphate]

pramlintidemonitor glucose: combo may incr. risk of hypoglycemia (additive/synergistic effects)

probenecidmonitor BP: combo may incr. ACE inhibitor duration of action, adverse effects (renal excretion decreased)

salicylatescaution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention)[salicylates: aspirin, aspirin/dipyridamole, carisoprodol/aspirin, choline magnesium trisalicylate, magnesium salicylate, oxycodone/aspirin, salsalate]

sodium phosphatesmonitor renal fxn: combo may incr. risk of nephrotoxicity (overlapping toxicity)[sodium phosphates: sodium phosphate, sodium phosphate rectal]

sodium sulfate/potassium sulfate/magnesium sulfatemonitor renal fxn, electrolytes: combo may incr. risk of nephrotoxicity, seizures (additive effects, electrolyte abnormalities)

sulfonylureasmonitor glucose: combo may incr. risk of hypoglycemia (mechanism unknown, possibly incr. insulin sensitivity)[sulfonylureas: chlorpropamide, glimepiride, glipizide, glyburide, glyburide micronized, tolazamide, tolbutamide]

sumatriptan/naproxen sodiummonitor BP, renal fxn: combo w/ NSAIDs may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

tacrolimusmonitor potassium: combo may incr. risk of hyperkalemia (additive effects)

telavancinmonitor renal fxn: combo may incr. risk of nephrotoxicity (additive effects)

tizanidinecaution advised, monitor BP: combo may incr. risk of hypotension (additive effects)

tolvaptanmonitor potassium: combo may incr. risk of hyperkalemia (additive effects)

trandolapril/verapamilavoid duplicate tx, monitor BP, potassium, renal fxn: combo may incr. risk of hypotension, hyperkalemia, renal dysfxn (additive effects, dual blockade of renin-angiotensin-aldosterone system)

trimethoprimmonitor potassium: combo may incr. risk of hyperkalemia (additive effects)

trimethoprim/sulfamethoxazolemonitor potassium: combo may incr. risk of hyperkalemia (additive effects)

Caution Advised

aldesleukincaution advised: combo may incr. risk of hypotension (additive effects)

apomorphinecaution advised: combo may incr. risk of orthostatic hypotension, MI, pneumonia, falls, other apomorphine adverse effects (additive effects)

black cohoshcaution advised: combo may incr. risk of hepatotoxicity (additive toxicity)[black cohosh: Actaea racemosa, baneberry, black cohosh (Actaea racemosa), black snakeroot, bugbane, bugwort, Cimicifuga racemosa, macrotys, rattle root, rattlesnake root, rattletop, rattleweed, squawroot]

capsicumcaution advised w/ topical capsicum: combo may incr. risk of cough (additive effects)[capsicum: African chilies, capsaicin, capsicum (Capsicum annuum), Capsicum annuum, cayenne, chili pepper, green chili pepper, Louisiana long pepper, Mexican chilies, paprika, pimento, red pepper, tabasco pepper]

gold sodium thiomalatecaution advised: combo may incr. risk of nitritoid rxn (synergistic effects)

icatibantcaution advised: combo may decr. ACE inhibitor efficacy (antagonistic effects)

iloprost inhaledcaution advised: combo may incr. risk of hypotension (additive/synergistic effects)

kavacaution advised: combo may incr. risk of hepatotoxicity (additive toxicity)[kava: ava pepper, awa, intoxicating pepper, kao, kava (Piper methysticum), kawa, kew, Piper methysticum, sakau, tonga, yagona]

MAOIs, non-selectivecaution advised: combo may incr. risk of hypotension (additive effects)[MAOIs, non-selective: isocarboxazid, phenelzine, procarbazine, selegiline transdermal, tranylcypromine]

maraviroccaution advised: combo may incr. risk of orthostatic hypotension (additive effects)

nitrites/sodium thiosulfatecaution advised: combo w/ nitrites may incr. risk of hypotension (additive effects)[nitrites/sodium thiosulfate: amyl nitrite/sodium nitrite/sodium thiosulfate, sodium nitrite/sodium thiosulfate]

PDE5 inhibitorscaution advised: combo may incr. risk of symptomatic hypotension (additive effects)[PDE5 inhibitors: sildenafil, tadalafil, vardenafil]

treprostinilcaution advised: combo may incr. risk of symptomatic hypotension (additive effects)[treprostinil: treprostinil, treprostinil inhaled]

Adverse Reactions

Serious Reactions

anaphylactoid rxns angioedema, head/neck

angioedema, intestinal

hypotension, severe

hyperkalemia

renal impairment/failure

hepatotoxicity

neutropenia

agranulocytosis

pancreatitis

Stevens-Johnson syndrome

oligohydramnios (in utero exposure)

fetal/neonatal harm or death (in utero exposure)

congenital malformations, major (1st trimester use)

Common Reactions

rash pruritus

taste changes

hypotension

dizziness

fatigue

cough

hyperkalemia

proteinuria

nausea/vomiting

BUN, Cr elevated

eosinophilia

positive ANA titers

myalgia

photosensitivity

hyperuricemia

Safety/Monitoring

Pregnancy: D (Positive evidence of human fetal risk; maternal benefit may outweigh fetal risk in serious or life-threatening situations; see pkg insert for drug-specific recs)

Lactation: Probably Safe (Limited information in animals and/or humans demonstrates no risk/minimal risk of adverse effects to infant/breast milk production; caution advised)

Monitoring Parameters BUN/Cr at baseline, then periodically, or more frequently if CHF, renal artery stenosis;

electrolytes; BP; WBC w/ diff at baseline if renal impairment, then q2wk x3mo, then periodically

Look/Sound-Alike Drug Names [from www.usp.org]

captopril confused with: calcitriol; carvedilol; Cytomel; enalapril

Pharmacology

Metabolism: liver; CYP450: unknown

Excretion: urine >95% (40-50% unchanged); Half-life: less than 3h

Subclass: ACE Inhibitors

Mechanism of Actioninhibits angiotensin converting enzyme, interfering w/ conversion of angiotensin I to angiotensin II

Manufacturer/Pricing

Manufacturer: generic

DEA/FDA: Rx: (Requires prescription; not a controlled substance)

Approximate Retail Price

from  www.drugstore.com

tablet:

12.5 mg (100 ea): $12.99 25 mg (90 ea): $13.99

50 mg (100 ea): $16.99

100 mg (90 ea): $19.99

Patient Education

Nombre Genérico: captopril

Nombre de la Marca: Capoten

¿Cuál es la información más importante que debo saber sobre captopril?

No use captopril si usted está embarazada. Deje de usar este medicamento y dígale de inmediato a su médico si queda embarazada. Captopril puede causarle daño o la muerte al bebé nonato si usted toma la medicina durante su segundo o tercer trimestre.

Beber alcohol puede bajar mucho más su presión arterial y puede aumentar ciertos efectos secundarios de captopril.

No use sustitutos de la sal o suplementos de potasio mientras esté tomando captopril, salvo que su médico le diga hacerlo.

Las condiciones que pueden causar una presión arterial muy baja incluyen: vómito, diarrea, sudor excesivo, enfermedad del corazón, diálisis, una dieta baja en sal, o tomar diuréticos (pastillas para eliminar el agua). Siga las instrucciones de su médico acerca de los tipos y cantidades de líquidos que debe beber mientras esté tomando captopril. Dígale a su médico si usted tiene una enfermedad de larga duración que le causa diarrea o vómito.

¿Qué es captopril?

Captopril es un inhibidor de la enzima convertidora de angiotensina (ECA; ACE, por sus siglas en Inglés).

Captopril se usa en el tratamiento de la presión arterial elevada (hipertensión), falla cardiaca congestiva, problema de los riñones causado por la diabetes, y para aumentar la supervivencia después de un ataque al corazón.

Captopril puede también usarse para fines no mencionados en esta guía del medicamento.

¿Qué debería discutir con el profesional del cuidado de la salud antes de tomar captopril?

Usted no debe usar este medicamento si tiene alergia a captopril o a algún otro inhibidor ECA (ACE, por sus siglas en Inglés), así como benazepril (Lotensin), fosinopril (Monopril), enalapril (Vasotec), lisinopril (Prinivil, Zestril), moexipril (Univasc), perindopril (Aceon), quinapril (Accupril), ramipril (Altace), o trandolapril (Mavik).

Para asegurarse que usted puede tomar captopril de forma segura, dígale a su médico si usted tiene cualquiera de estas otras condiciones:

enfermedad del riñón (o si está en diálisis);

enfermedad del hígado;

enfermedad del corazón o falla cardiaca congestiva;

diabetes; o

enfermedad del tejido conectivo, así como el síndrome de Marfan, síndrome de Sjogren, lupus, escleroderma, o artritis reumatoide.

Categoría D del embarazo por la FDA. No use captopril si usted está embarazada. Deje de usar este medicamento y dígale de inmediato a su médico si queda embarazada. Captopril puede causarle daño o la muerte al bebé nonato si usted toma la medicina durante su segundo o tercer trimestre. Use un método efectivo de control de la natalidad mientras están tomando captopril.

Captopril puede pasar a la leche materna y causarle daño al bebé lactante. Usted no debe amamantar mientras está usando captopril.

¿Cómo debo tomar captopril?

Tómelo exactamente como lo haya recetado su médico. No lo tome en cantidades mayores o menores, o por más tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripción.

Tal vez su médico en ocasiones cambie su dosis para asegurarse de que está obteniendo los mejores resultados.

Captopril por lo general se toma 1 hora antes de las comidas. Siga las instrucciones que ha recibido de su médico.

Las condiciones que pueden causar una presión arterial muy baja incluyen: vómito, diarrea, sudor excesivo, enfermedad del corazón, diálisis, una dieta baja en sal, o tomar diuréticos (pastillas para eliminar el agua). Siga las instrucciones de su médico acerca de los tipos y cantidades de líquidos que debe beber mientras esté tomando captopril. Dígale a su médico si usted tiene una enfermedad de larga duración que le causa diarrea o vómito.

Su presión arterial necesitará ser evaluada con frecuencia. La función de sus riñones y del hígado también serán examinada. Visite a su médico con regularidad.

Si necesita cirugía, dígale al cirujano en adelantado que usted está usando captopril. Quizás necesite dejar de usar la medicina por un breve tiempo.

Si usted está recibiendo tratamiento para la presión arterial alta, siga usando esta medicina aunque se sienta bien. La presión arterial alta frecuentemente no tiene síntomas. Usted tal vez necesite tomar medicina para la presión arterial el resto de su vida.

Guarde a temperatura ambiente lejos de la humedad y calor. Mantenga la botella bien cerrada cuando no se está usando.

¿Qué sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sáltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome más medicina para alcanzar la dosis pasada.

¿Qué sucedería en una sobredosis?

Busque atención médica de emergencia o llame a la línea de Poison Help al 1-800-222-1222.

Los síntomas de una sobredosis pueden incluir sentirse muy mareado o desmayo.

¿Qué debo evitar mientras tomo captopril?

Beber alcohol puede bajar mucho más su presión arterial y puede aumentar ciertos efectos secundarios de captopril.

No use sustitutos de la sal o suplementos de potasio mientras esté tomando captopril, salvo que su médico le indique hacerlo.

¿Cuáles son los posibles efectos secundarios del captopril?

Busque atención médica de emergencia si usted tiene alguno de estos síntomas de una reacción alérgica: ronchas; dolor intenso del estómago; dificultad para respirar; hinchazón de su cara, labios, lengua, o garganta.

Llame a su médico de inmediato si usted tiene un efecto secundario grave como:

sentirse mareado, desmayo; orinar más o menos de lo normal, o nada;

fiebre, escalofríos, dolor del cuerpo, síntomas de la gripe;

piel pálida, sentir que se va a desmayar o le falta aire al respirar, paso cardíaco rápido, dificultad para concentrarse;

moretones fáciles, sangrado inusual (nariz, boca, vagina, o recto), manchas debajo de la piel en forma de puntos morados o rojos;

latidos cardiacos desiguales, rápidos, o fuertes;

dolor de pecho; o

hinchazón, ganancia de peso rápida.

Efectos secundarios de menor gravedad pueden incluir:

tos; perdida de la sensación del sabor, perdida del apetito;

mareo, somnolencia, dolor de cabeza;

problemas para dormir (insomnio);

boca seca, llagas dentro de la boca o en sus labios;

náusea, diarrea, estreñimiento; o

leve picazón de la piel o sarpullido.

Esta lista no menciona todos los efectos secundarios y puede ser que ocurran otros. Llame a su médico para consejos médicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

¿Qué otras drogas afectarán a captopril?

Dígale a su médico acerca de todas las medicinas que usted use, especialmente:

inyecciones de oro para el tratamiento de la artritis; lithium (Lithobid, Eskalith);

suplemento de potasio, como K-Dur, Klor-Con;

sustitutos de la sal que contienen potasio;

drogas que dilatan los vasos sanguíneos, como alprostadil (Caverject, Edex), nitroglycerin, nitroprusside (Nitropress), nesiritide (Natrecor), minoxidil (Loniten), o isosorbide dinitrate (Imdur, Isordil);

aspirin u otro AINE (antiinflamatorio no esteroide; NSAID por sus siglas en Inglés) como ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn, Naprelan, Treximet), celecoxib (Celebrex), diclofenac (Arthrotec, Cambia, Cataflam, Voltaren, Flector Patch, Pennsaid, Solareze), indomethacin (Indocin), meloxicam (Mobic), y otras; o

un diurético (pastilla para eliminar el agua).

Esta lista no incluye todas las drogas y pueden existir otras que tengan interacciones con captopril. Dígale a su médico acerca de todos los medicamentos que usted use. Incluya los productos que se obtienen con o sin receta, vitaminas, y productos herbarios. No empiece a usar un medicamento nuevo sin primero decirle a su médico.

¿Dónde puedo obtener más información?

Su farmacéutico le puede dar más información acerca captopril (Capoten)

.

Drug

diphenhydraminegeneric

Entire Monograph

Adult Dosing

Dosage forms:  25,50; 12.5/5 mL; IM; IV

allergy sx

[25-50 mg PO/IM/IV q4-6h prn]Max: 100 mg/dose; 400 mg/day

allergic rxns, mod-severe

[25-50 mg PO/IM/IV q2-4h prn]Max: 100 mg/4h; 400 mg/day

extrapyramidal sx

[25-50 mg PO/IM/IV q6-8h prn]Max: 100 mg/dose; 400 mg/day

insomnia, short-term tx

[25-50 mg PO qhs prn]Info: give 30min before bedtime

motion sickness prevention

[25-50 mg PO/IM/IV q4-6h prn]Max: 300 mg/day; Info: start 30min before motion exposure

sedation

[25-50 mg PO/IM/IV q4-6h prn]Max: 300 mg/day

renal dosing

[no adjustment]HD/PD: no supplement

hepatic dosing

[not defined]

Peds Dosing

Dosage forms:  25,50; 12.5/5 mL; IM; IV

allergy sx

[*2-5 yo]Dose: 6.25 mg PO/IM/IV q4-6h prn; Max: 37.5 mg/day

[6-11 yo]Dose: 12.5-25 mg PO/IM/IV q4-6h prn; Max: 150 mg/day

[>12 yo]Dose: 25-50 mg PO/IM/IV q4-6h prn; Max: 100 mg/dose; 400 mg/day

allergic rxns, mod-severe

[2-11 yo]Dose: 1-2 mg/kg PO/IM/IV q6h prn; Max: 50 mg/dose; 300 mg/day

[>12 yo]Dose: 25-50 mg PO/IM/IV q2-4h prn; Max: 100 mg/4h; 400 mg/day

extrapyramidal sx

[2-11 yo]Dose: 1-2 mg/kg PO/IM/IV q6-8h prn; Max: 50 mg/dose; 300 mg/day

[>12 yo]Dose: 25-50 mg PO/IM/IV q6-8h prn; Max: 100 mg/dose; 400 mg/day

insomnia, short-term tx

[>12 yo]Dose: 25-50 mg PO qhs prn; Info: give 30min before bedtime

motion sickness prevention

[2-5 yo]

Dose: 6.25 mg PO/IM/IV q4-6h prn; Max: 37.5 mg/day; Info: start 30min before motion exposure

[6-11 yo]Dose: 12.5-25 mg PO/IM/IV q4-6h prn; Max: 150 mg/day; Info: start 30min before motion exposure

[>12 yo]Dose: 25-50 mg PO/IM/IV q4-6h prn; Max: 300 mg/day; Info: start 30min before motion exposure

renal dosing

[no adjustment]HD/PD: no supplement

hepatic dosing

[not defined]

Contraindications/Cautions

hypersens. to drug/class/compon. pts <2 yo

caution in pts <6 yo

caution in elderly pts

caution if CNS depressant use

caution if IOP incr.

caution if glaucoma, angle-closure

caution if hyperthyroidism

caution if cardiovascular dz

caution if HTN

caution if asthma

caution if COPD

caution if lower resp. tract sx

caution if GI obstruction

caution if PUD

caution if prostatic hypertrophy

caution if bladder neck obstruction

caution if poor CYP2D6 metabolizer

caution if high environmental temperature

Drug Interactions

Contraindicated

potassium chloridecontraindicated for solid potassium dose forms; use alternative dose forms: combo may delay solid potassium passage through GI tract, incr. risk of ulcerative/stenotic lesions (anticholinergics slow GI transit, incr. local exposure to high potassium concentration)

potassium citratecontraindicated for solid potassium dose forms; use alternative dose forms: combo may delay solid potassium passage through GI tract, incr. risk of ulcerative/stenotic lesions (anticholinergics slow GI transit, incr. local exposure to high potassium concentration)

sodium phosphate/potassium phosphatecontraindicated for solid potassium dose forms; use alternative dose forms: combo may delay solid potassium passage through GI tract, incr. risk of ulcerative/stenotic lesions (anticholinergics slow GI transit, incr. local exposure to high potassium concentration)

urinary acidifierscontraindicated for solid potassium dose forms; use alternative dose forms: combo may delay solid potassium passage through GI tract, incr. risk of ulcerative/stenotic lesions (anticholinergics slow GI transit, incr. local exposure to high potassium concentration)[urinary acidifiers: potassium acid phosphate, potassium acid phosphate/sodium acid phosphate]

Avoid/Use Alternative

haloperidolavoid combo or use alternative: combo may incr. risk of QT prolongation, cardiac arrhythmias, CNS depression, psychomotor impairment, anticholinergic adverse effects (hepatic metab. inhibited, additive effects)[haloperidol: haloperidol, haloperidol decanoate, haloperidol lactate]

MAOIs, allavoid combo w/in 14 days of MAO inhibitor use: combo may prolong and intensify anticholinergic effects of antihistamines (mechanism unknown)[MAOIs, all: isocarboxazid, phenelzine, procarbazine, rasagiline, selegiline, selegiline transdermal, tranylcypromine]

potassium iodideweigh risk/benefit of thyroid protection w/ solid potassium dose forms; use alternative dose forms if possible: combo may delay solid potassium passage through GI tract, incr. risk of ulcerative/stenotic lesions (anticholinergics slow GI transit, incr. local exposure to high potassium concentration)

pramlintideavoid or use alternative: combo w/ anticholinergic agents may further delay gastric emptying/slow GI transit (additive effects)

sodium oxybateavoid combo: combo may incr. risk of CNS depression, psychomotor impairment, adverse effects (additive effects)

Monitor/Modify Tx

dexmedetomidinecaution advised, consider dose reduction: combo may incr. risk of CNS depression, other adverse effects (additive effects)

Caution Advised

acetaminophen/caffeine/CNS depressant comboscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[acetaminophen/caffeine/CNS depressant combos: acetaminophen/caffeine/dihydrocodeine, butalbital/acetaminophen/caffeine, butalbital/acetaminophen/caffeine/codeine]

acetaminophen/chlorpheniraminecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

acetaminophen/chlorpheniramine/dextromethorphancaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

acetaminophen/chlorpheniramine/dextromethorphan/phenylephrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

acetaminophen/chlorpheniramine/phenylephrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

acetaminophen/codeinecaution advised: combo w/ opioids may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive/synergistic effects)

acetaminophen/diphenhydraminecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

acetaminophen/diphenhydramine/dextromethorphancaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

acetaminophen/diphenhydramine/phenylephrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

acetaminophen/doxylamine/dextromethorphancaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

acetaminophen/doxylamine/dextromethorphan/phenylephrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

acetaminophen/doxylamine/dextromethorphan/pseudoephedrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

acetaminophen/doxylamine/phenylephrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

acetaminophen/pheniramine/phenylephrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

aldesleukincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

anticholinergicscaution advised: combo may incr. anticholinergic adverse effects (additive effects)[anticholinergics: amantadine, atropine, benztropine, chlordiazepoxide/clidinium, dicyclomine, difenoxin/atropine, diphenoxylate/atropine, fesoterodine, flavoxate, glycopyrrolate, hyoscyamine, methscopolamine, oxybutynin, oxybutynin topical, oxybutynin transdermal, propantheline, scopolamine, scopolamine transdermal, tolterodine, trihexyphenidyl, trospium]

anticholinergics, ophthalmiccaution advised: combo may incr. anticholinergic adverse effects (additive effects)[anticholinergics, ophthalmic: atropine ophthalmic, cyclopentolate ophthalmic, homatropine ophthalmic, scopolamine ophthalmic, tropicamide ophthalmic]

antihistamine/decongestant comboscaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic and other adverse effects (additive effects, duplicate antihistamine tx)[antihistamine/decongestant combos: acrivastine/pseudoephedrine, brompheniramine/phenylephrine, chlorpheniramine/phenylephrine, chlorpheniramine/pseudoephedrine, diphenhydramine/phenylephrine]

antihistamines, sedatingcaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (additive effects)[antihistamines, sedating: brompheniramine, carbinoxamine, chlorpheniramine, clemastine, cyclizine, cyproheptadine, dexchlorpheniramine, dimenhydrinate, diphenhydramine, doxylamine, hydroxyzine, meclizine, triprolidine]

apomorphinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

aripiprazolecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)

asenapinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

aspirin/chlorpheniramine/dextromethorphancaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

aspirin/chlorpheniramine/dextromethorphan/phenylephrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

aspirin/chlorpheniramine/phenylephrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

aspirin/diphenhydraminecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

aspirin/doxylamine/dextromethorphan/phenylephrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

azelastine nasalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment

(additive effects)[azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal]

barbituratescaution advised: combo may incr. risk of CNS depression (additive effects)[barbiturates: butabarbital, methohexital, pentobarbital, phenobarbital, primidone, secobarbital, thiopental]

benzodiazepines, allcaution advised: combo may incr. risk of CNS depression (additive effects)[benzodiazepines, all: alprazolam, chlordiazepoxide, clobazam, clonazepam, clorazepate, diazepam, diazepam rectal, estazolam, flurazepam, lorazepam, midazolam, oxazepam, temazepam, triazolam]

botulinum toxinscaution advised: combo may incr. risk of anticholinergic adverse effects (additive effects)[botulinum toxins: abobotulinumtoxinA, incobotulinumtoxinA, onabotulinumtoxinA, rimabotulinumtoxinB]

brompheniramine/dextromethorphan/phenylephrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

brompheniramine/dextromethorphan/pseudoephedrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

buprenorphinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[buprenorphine: buprenorphine, buprenorphine transdermal, buprenorphine/naloxone]

butalbital/acetaminophencaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

butorphanolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

butorphanol nasalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

calendulacaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[calendula: bride of the sun, calendula (Calendula officinalis), Calendula officinalis, garden marigold, gold-bloom, golden flower of Mary, holligold, marigold, marybud, pot marigold]

cannabinoidscaution advised: combo may incr. risk of tachycardia, drowsiness, CNS depression, psychomotor impairment (additive/synergistic effects)[cannabinoids: dronabinol, nabilone]

capsicumcaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[capsicum: African chilies, capsaicin, capsicum (Capsicum annuum), Capsicum annuum, cayenne, chili pepper, green chili pepper, Louisiana long pepper, Mexican chilies, paprika, pimento, red pepper, tabasco pepper]

carbamazepinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

carisoprodol/aspirincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

central alpha 2 agonistscaution advised: combo may incr. risk of CNS depression (additive effects)[central alpha 2 agonists: clonidine, clonidine transdermal, guanabenz, guanfacine, methyldopa]

cetirizinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (duplicate tx)

cetirizine/pseudoephedrinecaution advised: combo may incr. risk of CNS depression and other adverse effects (duplicate tx)

chamomile, Germancaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[chamomile, German: chamomile, German (Matricaria recutita), chamomile, Hungarian, chamomile, wild, Chamomilla recutita, Matricaria chamomilla, Matricaria recutita, pin heads]

chlorpheniramine/dextromethorphancaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

chlorpheniramine/dextromethorphan/pseudoephedrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

chlorpheniramine/hydrocodonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment; some antihistamines may potentiate opioid analgesic effects (additive/synergistic effects)

cholinergic agentscaution advised: combo may decr. efficacy of both (antagonistic effects)[cholinergic agents: bethanechol, cevimeline, pilocarpine]

cholinergic agents, ophthalmiccaution advised: combo may decr. efficacy of ophthalmic cholinergic agent (antagonistic effects)[cholinergic agents, ophthalmic: carbachol ophthalmic, pilocarpine ophthalmic]

clozapinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)

CNS depressant/aspirin/caffeine comboscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[CNS depressant/aspirin/caffeine combos: butalbital/aspirin/caffeine, butalbital/aspirin/caffeine/codeine, dihydrocodeine/aspirin/caffeine]

cyclopentolate/phenylephrine ophthalmiccaution advised: combo may incr. anticholinergic adverse effects (additive effects)

dantrolenecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

darifenacincaution advised: combo may incr. anticholinergic adverse effects (additive effects)

disopyramidecaution advised: combo may incr. anticholinergic adverse effects (additive effects)

doxazosincaution advised w/ doxazosin ER dosage form: combo may incr. doxazosin levels, risk of adverse effects (absorption increased, slower GI transit due to anticholinergic effects)

doxylamine/dextromethorphancaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

droperidolcaution advised: combo may incr. risk of CNS depression (additive effects)

eltrombopagcaution advised: combo may incr. diphenhydramine levels, risk of adverse effects (hepatic metab. inhibited)

epinephrinecaution advised: combo w/ diphenhydramine may incr. epinephrine adverse effects (mechanism unknown)

ethanolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

ethosuximidecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

ezogabinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, urinary retention, other adverse effects (additive effects)

gabapentincaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[gabapentin: gabapentin, gabapentin enacarbil]

ginseng, Siberiancaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[ginseng, Siberian: Acanthopanax senticosus, devil's bush, eleuthero, eleutherococcus, Eleutherococcus senticosus, ginseng, Siberian (Eleutherococcus senticosus), shigoka, thorny pepperbush, Touch-Me-Not, untouchable, wild pepper]

goldensealcaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[goldenseal: berberine, eye balm, eye root, goldenseal (Hydrastis canadensis), ground raspberry, Hydrastis canadensis, Indian plant, jaundice root, orange root, wild curcuma, yellow root]

gotu kolacaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[gotu kola: brahma-buti, Centella asiatica, gotu kola (Centella asiatica), hydrocotyle, Indian pennywort, Indian water navelwort, madescassol, marsh penny, talepetrako, thick-leaved pennywort, white rot]

hawthorncaution advised: combo may incr. risk of CNS depressant effects (additive effects)[hawthorn: aubepine, Chinese hawthorn, Crataegus laevigata, Crataegus monogyna, Crataegus oxyacantha, Crataegus pentagyna, English hawthorn, hawthorn (Crataegus spp.), hedgethorn, maybush, maythorn, oneseed hawthorn, shanzha, whitehorn]

hydrocodone/acetaminophencaution advised: combo w/ opioids may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive/synergistic effects)

hydrocodone/chlorpheniramine/pseudoephedrinecaution advised: combo of opioids and sedating antihistamines may incr. risk of CNS depression, psychomotor impairment, anticholinergic and other adverse effects (additive effects, duplicate tx)

hydrocodone/ibuprofencaution advised, consider opioid dose reduction: combo may incr. risk of severe constipation/paralytic ileus, CNS depression, psychomotor impairment, other adverse effects (additive effects)

hydrocodone/pseudoephedrinecaution advised, consider lower hydrocodone doses: combo of opioids and sedating antihistamines may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive effects)

iloperidonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

kavacaution advised: combo may incr. risk of sedation, psychomotor impairment (additive effects)[kava: ava pepper, awa, intoxicating pepper, kao, kava (Piper methysticum), kawa, kew, Piper methysticum, sakau, tonga, yagona]

lemon balmcaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[lemon balm: balm, bee balm, cure-all, dropsy plant, honey plant, lemon balm (Melissa officinalis), Melissa, Melissa folium, Melissa officinalis, sweet balm, sweet Mary]

levocetirizinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (duplicate tx)

loperamidecaution advised: combo may incr. risk of severe constipation/paralytic ileus (additive effects)[loperamide: loperamide, loperamide/simethicone]

loxapinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)

lurasidonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

maprotilinecaution advised: combo may incr. risk of CNS depression (additive effects)

meprobamatecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

methadonecaution advised, consider opioid dose reduction: combo may incr. risk of severe constipation/paralytic ileus, CNS depression, psychomotor impairment, other adverse effects (additive effects)

metoclopramidecaution advised: combo may decr. GI prokinetic effects, incr. risk of CNS depression (antagonistic effects, additive effects)

mirabegroncaution advised: combo w/ antihistamines may incr. risk of urinary retention, other adverse effects (additive effects)

mirtazapinecaution advised: combo may incr. risk of CNS depression (additive effects)

mitotanecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

morphine liposomalcaution advised: combo may incr. risk of CNS depression, profound sedation, other adverse effects (additive effects)

muscle relaxantscaution advised: combo may incr. risk of CNS depression (additive effects)[muscle relaxants: baclofen, baclofen intrathecal, carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine, tizanidine]

nalbuphinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

nefazodonecaution advised: combo may incr. risk of CNS depression (additive effects)

NSAID/chlorpheniramine/pseudoephedrine comboscaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)[NSAID/chlorpheniramine/pseudoephedrine combos: ibuprofen/chlorpheniramine/pseudoephedrine]

NSAID/diphenhydramine comboscaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)[NSAID/diphenhydramine combos: ibuprofen/diphenhydramine]

olanzapinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)

olanzapine/fluoxetinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)

olopatadine nasalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

opiate/aspirin comboscaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[opiate/aspirin combos: carisoprodol/aspirin/codeine, oxycodone/aspirin]

opiatescaution advised, consider opioid dose reduction: combo may incr. risk of severe constipation/paralytic ileus, CNS depression, psychomotor impairment, other adverse effects (additive effects)[opiates: alfentanil, codeine phosphate, codeine sulfate, codeine/guaifenesin, fentanyl, fentanyl nasal, fentanyl transdermal, fentanyl transmucosal, hydrocodone/homatropine, hydromorphone, levorphanol, meperidine, morphine sulfate, morphine sulfate/naltrexone, oxycodone, oxymorphone, remifentanil, sufentanil]

oxcarbazepinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

oxycodone/acetaminophencaution advised: combo w/ opioids may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive/synergistic effects)

oxycodone/ibuprofencaution advised: combo of antihistamines and opioids may incr. risk of severe constipation/paralytic ileus, CNS depression, psychomotor impairment, other adverse effects (additive effects)

paliperidonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)[paliperidone: paliperidone, paliperidone palmitate]

passionflowercaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[passionflower: apricot vine, corona de cristo, Fleischfarbige, fleur de la passion, maypop, Passiflora incarnata, passion vine, passionflower (Passiflora incarnata), purple passion flower, water lemon, wild passion flower]

pentazocinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive/synergistic effects)[pentazocine: pentazocine lactate, pentazocine/acetaminophen, pentazocine/naloxone]

pheniramine/dextromethorphan/phenylephrinecaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

phenobarbital/hyoscyamine/atropine/scopolaminecaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)

phenothiazinescaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)[phenothiazines: chlorpromazine, fluphenazine, fluphenazine decanoate, perphenazine, prochlorperazine edisylate, prochlorperazine maleate, prochlorperazine rectal, promethazine, promethazine rectal, thioridazine, trifluoperazine]

pimozidecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)

pramipexolecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

pregabalincaution advised: combo may incr. risk of CNS depression, psychomotor impairment, adverse effects (additive effects)

promethazine/codeinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)

propofolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[propofol: fospropofol, propofol]

propoxyphenecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[propoxyphene: propoxyphene hydrochloride, propoxyphene napsylate]

propoxyphene/acetaminophencaution advised: combo w/ propoxyphene may incr. risk of CNS depression, psychomotor impairment (additive effects)

[propoxyphene/acetaminophen: propoxyphene hydrochloride/acetaminophen, propoxyphene napsylate/acetaminophen]

quetiapinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)

risperidonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)

ropinirolecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

rotigotine transdermalcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

rufinamidecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

sedative/hypnoticscaution advised, consider sedative/hypnotic dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[sedative/hypnotics: chloral hydrate, eszopiclone, zaleplon, zolpidem]

solifenacincaution advised: combo may incr. anticholinergic adverse effects (additive effects)

tamoxifencaution advised: combo w/ diphenhydramine may decr. active tamoxifen metabolite levels, efficacy (hepatic metab. inhibited)

tapentadolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

tetrabenazinecaution advised: combo may incr. tetrabenazine active metabolite levels, risk of adverse effects; incr. risk of CNS depression, psychomotor impairment (hepatic metab. inhibited; additive effects)

thalidomidecaution advised: combo may incr. risk of CNS depression (additive effects)

thiothixenecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)

tiagabinecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

topiramatecaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[topiramate: phentermine hydrochloride/topiramate, topiramate]

tramadolcaution advised: combo may incr. risk of CNS depression, psychomotor impairment; combo w/ diphenhydramine may incr. tramadol or decr. metabolite levels, incr. toxicity or alter efficacy (additive effects; hepatic metab. inhibited, decr. conversion to active metabolite)

tramadol/acetaminophencaution advised: combo w/ tramadol may incr. risk of CNS depression, psychomotor impairment (additive effects)

trazodonecaution advised: combo may incr. risk of CNS depression (additive effects)

tricyclic antidepressantscaution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (additive effects)[tricyclic antidepressants: amitriptyline, amoxapine, chlordiazepoxide/amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, perphenazine/amitriptyline, protriptyline, trimipramine]

valeriancaution advised: combo may incr. risk of sedation, other adverse effects (additive effects)[valerian: all-heal, amantilla, baldrian, baldrianwurzel, garden heliotrope, herba benedicta, valerian (Valeriana officinalis), Valeriana edulis, Valeriana jatamansii, Valeriana officinalis, Valeriana sitchensis, Valeriana wallichii]

valproic acid derivativescaution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)[valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid]

vigabatrincaution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

ziconotide intrathecalcaution advised: combo may incr. risk of confusion, dizziness, other CNS adverse effects (additive effects)[ziconotide intrathecal: ziconotide]

ziprasidonecaution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)

zonisamidecaution advised: combo w/ drugs possessing anticholinergic effects may incr. risk of oligohidrosis, hyperthermia, and heat stroke especially in children (additive effects)

Adverse Reactions

Serious Reactions

anaphylactic/anaphylactoid rxns anemia, hemolytic

thrombocytopenia

agranulocytosis

leukopenia

pancytopenia

arrhythmias

seizures

toxic psychosis

labyrinthitis, acute

heat stroke

Common Reactions

drowsiness dizziness

incoordination

headache

epigastric discomfort

thickened bronchial secretions

dry mucous membranes

CNS stimulation, paradoxical

constipation

dysuria

urinary retention

hypotension

blurred vision

diplopia

palpitations

tachycardia

photosensitivity

diaphoresis

erectile dysfxn

Safety/Monitoring

Pregnancy: B (Animal studies show no risk or adverse fetal effects but controlled human 1st trimester studies not avail/do not confirm; no evidence of 2nd or 3rd trimester risk; fetal harm possible but unlikely; see pkg insert drug-specific recs)

Lactation: Probably Safe (Limited information in animals and/or humans demonstrates no risk/minimal risk of adverse effects to infant/breast milk production; caution advised)

Monitoring Parameters Cr at baseline (peds pts)

Look/Sound-Alike Drug Names [from www.usp.org]

diphenhydrAMINE confused with: dicyclomine; dimenhyDRINATE; dipyridamole

Pharmacology

Metabolism: liver; CYP450: 2D6 substrate/inhibitor

Excretion: urine (minimally unchanged); Half-life: 3.4-9.2h

Subclass: Vertigo/Motion Sickness; Parkinson Dz/Dystonia; Antihistamines, 1st generation; Insomnia

Mechanism of Actionnon-selectively antagonizes central and peripheral histamine H1 receptors; suppresses the medullary cough center (antitussive); possesses anticholinergic properties, resulting in antidyskinetic, antiemetic and sedative effects

Manufacturer/Pricing

Manufacturer: generic

DEA/FDA: OTC/Rx: (Some formulations require prescription)

Approximate Retail Price

from  www.drugstore.com

solution:

50 mg/ml (25 vials, 1 ml): $35.99

capsule:

25 mg (30 ea): $11.99

Patient Education

Nombre Genérico: diphenhydramine

Nombres de las Marcas: Aler-Tab, Allergy, Allermax, Altaryl, Benadryl Allergy, Benadryl DF, Benadryl Dye Free Allergy, Benadryl Ultratab, Children's Allergy, Diphen Cough, Diphenhist, Dytuss, PediaCare Children's Allergy, Q-Dryl, Q-Dryl A/F, Siladryl, Siladryl Allergy, Silphen Cough, Simply Sleep, Sleep-ettes, Sleep-ettes D, Sominex Maximum Strength Caplet, Theraflu Thin Strips Multi Symptom, Triaminic Thin Strips Cough & Runny Nose, Unisom Sleepgels Maximum Strength, Valu-Dryl

¿Cuál es la información más importante que debo saber sobre diphenhydramine?

Tenga cuidado al conducir, al operar maquinaria, o al hacer otras actividades peligrosas. Diphenhydramine podría causar mareos o somnolencia. Si usted siente mareos o somnolencia, evite estas actividades.

Use las bebidas alcohólicas con cuidado. El alcohol podría aumentar la somnolencia y los mareos mientras esté tomando diphenhydramine.

¿Qué es diphenhydramine?

Diphenhydramine es un antihistamínico. Éste bloquea los efectos de la sustancia química natural histamina en su cuerpo.

Diphenhydramine se usa para impedir el estornudo; nariz mucosa; ojos llorosos, con picazón; ronchas; sarpullido; picazón; y otros síntomas de alergias y del resfriado común.

Diphenhydramine también se usa para detener la tos, tratar los mareos causados por movimiento, inducir sueño, y para el tratamiento de la enfermedad de Parkinson de presentación leve.

Diphenhydramine podría también ser usada para propósitos diferentes a los que están incluidos en esta guía del medicamento.

¿Qué debería discutir con el profesional de la salud antes de tomar diphenhydramine?

No tome diphenhydramine si usted ha tomado inhibidores de la monoaminooxidasa (IMAO) como isocarboxazida (Marplan), fenelzina (Nardil), y tranilcipromina (Parnate) en los últimos 14 días. Una interacción de drogas muy peligrosa puede ocurrir, resultando en efectos secundarios de gravedad.

Antes de tomar este medicamento, dígale a su médico si usted tiene

glaucoma o elevación de la presión en el ojo; una úlcera estomacal;

la próstata inflamada, problemas de la vejiga, o dificultad para orinar;

la tiroides sobre activa (hipertiroidismo);

presión arterial alta (hipertensión) o cualquier tipo de problema del corazón; o

asma.

Quizás usted no pueda tomar diphenhydramine o tal vez necesite una dosis más baja o un cuidado especial durante el tratamiento si tiene cualquiera de las condiciones mencionadas anteriormente.

Diphenhydramine está clasificada por la FDA en la categoría B de Riesgos a la Gestación. Esto significa que es improbable que dañe al bebé nonato. No tome diphenhydramine sin antes hablar con su médico si está embarazada.

Los infantes son muy sensibles a los efectos de antihistamínicos, y efectos secundarios graves pueden ocurrir en un bebé que está amamantando. Diphenhydramine no es recomendado si usted dando de amamantar. Si está amamantando al bebé, no tome este medicamento sin antes consultar con su médico.

Si usted tiene más de 60 años de edad, es más probable que usted note los efectos secundarios de diphenhydramine. Quizás usted necesite una dosis más baja de este medicamento.

¿Cómo debo tomar la diphenhydramine?

Tome diphenhydramine exactamente como lo indique su médico. Si no entiende estas instrucciones, pídale a su médico, enfermera, o farmacéutico que se las aclaren.

Tome cada dosis con un vaso de agua lleno.

Diphenhydramine puede tomarse con o sin alimento.

Para los mareos causados por movimiento, una dosis se toma normalmente 30 minutos antes de movimiento, luego con las comidas y a la hora de acostarse por la duración de la exposición al movimiento.

Para ayudarlo dormir, diphenhydramine debería tomarse aproximadamente 30 minutos antes de la hora de acostarse.

Para asegurar de que usted recibe la dosis correcta, mida las forma líquida de diphenhydramine con una cucharadita o taza especial de medir, y no con una cuchara regular de servir. Si usted no tiene un aparato para medir su dosis, pregúntele a su farmacéutico donde puede conseguir uno.

Nunca tome más de este medicamento de lo que le hayan prescrito. La cantidad máxima de diphenhydramine que se puede tomar en un periodo de 24 horas es (1 día) es 300 mg.

Mantenga diphenhydramine a temperatura ambiente fuera de la humedad y del calor.

¿Qué sucede si dejo de tomar una dosis?

En cuanto se acuerde, tome la dosis olvidada. Sin embargo, si ya es casi la hora para su próxima dosis, espere y tome solamente la próxima dosis regularmente fijada. No tome doble dosis de este medicamento a menos que sea indicado de lo contrario por su médico.

¿Qué sucede si tomo una sobredosis?

Busque atención médica de emergencia.

Los síntomas de una sobredosis de diphenhydramine incluyen sueño extremo, confusión, debilidad, zumbido en los oídos, vista borrosa, pupilas grandes, boca seca, enrojecimiento, fiebre, temblores, insomnio, alucinaciones, y posiblemente convulsiones.

¿Qué debo evitar mientras tomo diphenhydramine?

Tenga cuidado al conducir, al operar maquinaria, o al hacer otras actividades peligrosas. Diphenhydramine podría causar mareos o somnolencia. Si usted siente mareos o somnolencia, evite estas actividades.

Use las bebidas alcohólicas con cuidado. El alcohol podría aumentar la somnolencia y los mareos mientras usted esté tomando diphenhydramine.

¿Cuáles son los efectos secundarios posibles de diphenhydramine?

Pare de tomar diphenhydramine y busque atención médica de emergencia si usted nota una reacción alérgica (dificultad para respirar; cierre de su garganta; hinchazón de sus labios, lengua, o cara; o ronchas).

Otros efectos secundarios de menos importancia podrían ser más probables de ocurrir. Siga tomando diphenhydramine y consulte con su médico si nota

sueño, cansancio, o mareos; dolor de cabeza;

boca seca; o

dificultad para orinar o la próstata inflamada.

Esta lista no menciona todos los efectos secundarios y puede ser que ocurran otros. Llame a su médico para consejos médicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

¿Que otras drogas afectarán a la diphenhydramine

No tome diphenhydramine si usted ha tomado inhibidores de la monoaminooxidasa (IMAO) como isocarboxazida (Marplan), fenelzina (Nardil), y tranilcipromina (Parnate) en los últimos 14 días. Una interacción de drogas muy peligrosa puede ocurrir, resultando en efectos secundarios serios.

Consulte con su farmacéutico antes de tomar otros medicamentos sin prescripción para la tos, resfriado, alergia, o insomnio. Éstos productos podrían contener medicamentos similares a diphenhydramine, lo cual puede resultar en una sobredosis de antihistamínicos.

Antes de tomar este medicamento, dígale a su médico si usted está tomando cualquiera de las siguientes medicinas:

medicinas para la ansiedad o para dormir como alprazolam (Xanax), diazepam (Valium), chlordiazepoxide (Librium), temazepam (Restoril), o triazolam (Halcion);

antidepresivos como amitriptyline (Elavil), doxepin (Sinequan), nortriptyline (Pamelor), fluoxetine (Prozac), sertraline (Zoloft), o paroxetine (Paxil); o

cualquier otro medicamento que lo haga sentir somnoliento, soñoliento, o relajado.

Además de las drogas mencionadas anteriormente, otras también podrían tener interacciones con diphenhydramine. Consulte con su médico y farmacéutico antes de tomar cualquier medicamento, ya sea recetado o no.

¿Dónde puedo obtener más información?

Su farmacéutico tiene más información acerca de diphenhydramine (Benadryl).