Drug Interactions

Common Drugs Interactions

CARDIOVASCULAR Drug-Intxns INHIBITORS INCREASE Substrate Drugs
Interaction Risk Actions By Interaction Risk Actions By
Pharmacist/Notes Pharmacist/Notes
Amiodarone If using amiodarone 1st and CYP 3A4 DECREASED CYP3A4 Do not use a CYP3A4 inhibitor with an
+ Warfarin Amiodarone inhibits adding warfarin: Start warfarin at substrate (i.e., drug) opioid metabolized by CYP3A4; the
multiple enzymes,
Inhibitors metabolism will cause combination will cause increased
a lower dose of < 5 mg.
*Can be used together for arterial including CYP2C9, which + CYP 3A4 INCREASED drug ADRs, including sedation, and can be
fibrillation treatment: amiodarone (for metabolizes the more If using warfarin 1st and adding Substrates levels and INCREASED fatal.
rhythm control), warfarin (to reduce potent warfarin isomer. amiodarone: *Includes the opioids ADRs/toxicity.
clot risk). fentanyl, hydrocodone, Grapefruit/grapefruit juice: do not take
DECREASE warfarin dose 30-50%, oxycodone, methadone
DECREASED warfarin If an opioid is the with CYP3A4 substrates. Drugs that
*Dronedarone has similar drug depending on the INR.
metabolism causes substrate, sedation will specifically include instructions not to
interaction issue.
INCREASED INR and increase, followed by take with grapefruit include
bleeding risk. Taking both respiratory depression, amiodarone, simvastatin, lovastatin,
Monitor INR; adjust as needed. which can quickly cause nifedipine and tacrolimus; many other
fatality. drugs have similar risk.
Amiodarone Amiodarone inhibits P- If using amiodarone 1st and Valproate Valproate DECREASE Initiate lamotrigine using the starter kit
+ Digoxin gp; digoxin is a P-gp adding digoxin: Start oral digoxin Lamotrigine metabolism that begins with lower lamotrigine
substrate.
+ Lamotrigine and INCREASED doses. Titrate carefully every 2 weeks.
at a low dose, such as 0.125 mg *Valproate is an inhibitor
*Can be given together for atrial daily. of lamotrigine Lamotrigine levels
fibrillation treatment: amiodarone (for DECREASED digoxin metabolism causing INCREASED Counsel patients to get emergency
rhythm control), digoxin (for rate excretion, INCREASED If using digoxin 1st and adding risk serious skin help if rash develops.
control (DECREASED HR), or for ADRs/toxicity. amiodarone: reactions, including
symptom improvement in a patient SJS/TEN (can be fetal)
with HF) DECREASE oral digoxin dose 50%
Amiodarone and digoxin
(e.g., change 0.25 mg daily to 0.125
both DECREASED HR,
mg daily, or change 0.125 mg daily
INCREASED risk of
bradycardia, arrhythmia, to 0.125 mg every other day).
fatality.
Taking both amiodarone and
digoxin: MOA Inhibitors The MAO enzyme Do not use together.
* lsocarboxazid, phenelzine, metabolizes Epi, NE,
- Instruct patient to monitor for tranylcypromine, rasagiline, DA, tyramine, and 5-HT. Use a 2-week washout period when
Loop diuretics symptoms of digoxin toxicity: selegiline, linezolid, switching between drugs with MAO
DECREASED K, Mg, Ca methylene blue Blocking MAO with an inhibition or serotonergic properties
Digoxin nausea, vomiting, vision changes;
and Na. if present, contact prescriber. MAO- inhibitor will (except with fluoxetine, wait 5 weeks).
+ Loop Diuretics + Drugs/foods INCREASED Epi, NE,
Low K, Mg or Ca will - Monitor HR; normal is 60-100 that INCREASED DA and 5-HT. Tyramine-rich foods have been aged,
*Can be given together for heart worsen arrhythmias. BPM (can be lower, based on pickled, fermented, or smoked,
failure treatment: digoxin (for patient's history and physical Epi, NE, and DA High Epi, NE and DA including aged cheeses, air-dried
symptom improvement), loop * SNRls, TCAs, bupropion,
Digoxin toxicity risk is state). Check for other drugs that can cause hypertensive meats, sauerkraut, some wines and
diuretics (to alleviate symptoms due levodopa, stimulants,
to fluid overload) increased with DECREASE HR: beta-blockers, crisis. beers.
including amphetamines
DECREASED K and Mg clonidine, diltiazem, verapamil, used for ADHD (e.g.,
levels and INCREASED dexmedetomidine (Precedex). methylphenidate, High 5-HT can cause
Ca levels. lisdexamfetamine, serotonin syndrome.
- If digoxin is being used for rate dextroamphetamine),
Caution: HF and renal control, inform prescribers to tyramine (from foods)
impairment often occur consider beta-blockers or non-
together. Digoxin is DHP CCBs instead. + Drugs that
cleared by P-gp and INCREASED 5-
 excreted by the kidneys; Taking digoxin and a loop HT
renal impairment (which diuretic: *Antidepressants: SSRIs,
can be exacerbated by SNRIs, TCAs, mirtazapine,
loop diuretics) - trazodone
INCREASED digoxin Monitor electrolytes and correct if *Opioids and analgesics:
abnormal. fentanyl, methadone,
levels and toxicity risk.
tramadol
- *Others: buspirone,
Renal impairment: DECREASE dextromethorphan (when
high doses taken as drug of
digoxin dose or frequency, or abuse), lithium, St. John’s
discontinue wort
Drugs the DECREASE CYP2D6 DECREASED drug Avoid using together, if possible.
Heart Rate Additive effects when Inhibitors substrate metabolism,
drugs that DECREASED Monitor HR; normal is 60-100 BPM *Amiodarone, fluoxetine, INCREASE
*Diltiazem/Verapamil or beta- HR are used together, (can be lower, based on patient's paroxetine, fluvoxamine ADRs/toxicity (or
blockers for rate control; clonidine including amiodarone, history and physical state). decreased clinical
and beta-blockers to lower blood digoxin, beta-blockers, efficacy if a prodrug)
pressure. + CYP2D6
clonidine, diltiazem,
substrates
verapamil and *Many, including
dexmedetomidine codeine, meperidine,
(Precedex). tramadol, tamoxifen
Statins CYP3A4, P-GP DECREASED drug Avoid using together or DECREASED
+ Strong CYP3A4 INCREASED levels of Simvastatin and lovastatin are Inhibitors substrate metabolism, dose of CNI or mTOR kinase inhibitor
Inhibitors CYP3A4 substrates: contraindicated with strong CYP3A4 + INCREASED cautiously and based on drug levels.
lovastatin, simvastatin, inhibitors. Recommend a statin not ADRs/toxicity, including
atorvastatin. metabolized by CYP450 enzymes Calcineurin INCREASED blood Monitor transplant drug levels.
*Inhibitors: Protease Inhibitors Inhibitors (CNIs)
(including ritonavir), Cobicistat, (e.g., pitavastatin, pravastatin, pressure,
INCREASED myopathy rosuvastatin) *Tacrolimus, nephrotoxicity,
Clarithromycin, Erythromycin, Cyclosporine
Azole antifungals, cyclosporine, risk; if severe (with high metabolic syndrome,
grapefruit CPK), can cause Or and other adverse
rhabdomyolysis with mTOR kinase effects
acute renal failure (ARF). Inhibitors
*Sirolimus, Everolimus
Warfarin
+ CYP2C9 Inhibitors INCRESASED levels of Monitor INR; therapeutic range is 2-
and Inducers warfarin (INCREASED 3 for most conditions (2.5-3.5 for
INR and bleeding risk) some high-risk indications, such as
with CYP2C9 inhibitors. mechanical mitral valve).
*Inhibitors: Azole Antifungals,
Sulfamethoxazole/trimethoprim,
Amiodarone, Metronidazole DECREASED levels of Some drugs (e.g., amiodarone)
warfarin (DECREASED require prophylactic warfarin dose
*Inducers: Rifampin, St. John’s Wort INR and INCREASED adjustment when started (see
clotting risk) with above).
CYP2C9 inducers.