OTC

Tagamet HB 200
cimetidine

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

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

Avoid/Use Alternative

atazanavir avoid 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 substrates use 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 combos use 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, systemic use 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, others use alternative: combo may incr. risk of bradycardia, hypotension (hepatic metab. inhibited) [calcium channel blockers, others: diltiazem, trandolapril/verapamil, verapamil]

cefditoren use alternative: combo may decr. cefditoren levels, efficacy (absorption decreased) cefpodoxime use alternative: combo may decr. cefpodoxime levels, efficacy (absorption decreased) cefuroxime use alternative: combo may decr. oral cefuroxime levels, efficacy (absorption decreased at higher gastric pH) [cefuroxime: cefuroxime axetil, cefuroxime sodium] clopidogrel avoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite) dasatinib use alternative: combo may decr. dasatinib levels, efficacy (absorption decreased at higher gastric pH) delavirdine use alternative: combo may decr. delavirdine efficacy (absorption decreased) epirubicin avoid combo: combo may incr. epirubicin levels, risk of toxicity (mechanism unknown) erlotinib avoid 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/simvastatin use alternative: combo may incr. simvastatin levels, risk of myopathy, rhabdomyolysis (hepatic metab. inhibited) iron salts, oral use alternative or give iron 1h before: combo may decr. iron efficacy (absorption decreased at higher gastric pH) [iron salts, oral: ferrous gluconate, ferrous sulfate] itraconazole use alternative or admin. itraconazole w/ cola to incr. acidity: combo may decr. antifungal efficacy (absorption decreased, requires acid pH) ketoconazole use alternative or admin. ketoconazole w/ cola to incr. acidity: combo may decr. antifungal efficacy (absorption decreased, requires acid pH) linagliptin/metformin use alternative: combo may incr. metformin levels, risk of adverse effects including lactic acidosis (renal excretion decr. by competition for active tubular transport) mesalamine avoid combo; does not apply to Pentasa formulation: combo may decr. mesalamine efficacy (premature dissolution occurs if gastric pH increased) metformin/sulfonylurea combos use alternative: combo may incr. metformin levels, risk of adverse effects including lactic acidosis (renal excretion decreased) [metformin/sulfonylurea combos: glipizide/metformin, glyburide/metformin] metformins use alternative: combo may incr. metformin levels, risk of adverse effects including lactic

acidosis (renal excretion decreased) [metformins: metformin, pioglitazone/metformin, repaglinide/metformin, rosiglitazone/metformin] naproxen avoid 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] nevirapine use alternative: combo may incr. nevirapine levels (hepatic metab. inhibited) posaconazole weigh risk/benefit: combo may decr. posaconazole levels, efficacy (mechanism unknown, absorption possibly altered) quinidine use alternative: combo may incr. quinidine levels, risk of toxicity (hepatic metab. inhibited) [quinidine: quinidine gluconate, quinidine sulfate] saxagliptin/metformin use alternative: combo may incr. metformin levels, risk of adverse effects including lactic acidosis (renal excretion decr. by competition for active tubular transport) sirolimus use alternative or monitor levels: combo may incr. sirolimus levels, risk of toxicity (gastrointestinal, hepatic metab. inhibited) sitagliptin/metformin use 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) tacrine use alternative H2 blocker or monitor for adverse effects: combo may incr. tacrine levels, risk of cholinergic adverse effects (hepatic metab. inhibited) terbinafine use alternative: combo may incr. terbinafine levels, risk of toxicity (hepatic metab. inhibited, clearance decreased 33%) tizanidine avoid combo or use alternative: combo may incr. tizanidine levels, incr. risk of hypotension, bradycardia, psychomotor impairment, other adverse effects (hepatic metab. inhibited) tricyclic antidepressants use 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] zolmitriptan use 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/caffeine monitor 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 monitor 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 combos 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 combos: acetaminophen/caffeine/dihydrocodeine, butalbital/acetaminophen/caffeine, butalbital/acetaminophen/caffeine/codeine] acyclovir caution advised, decr. acyclovir dose only if renal impairment: combo may incr. acyclovir levels (renal excretion decreased) alfentanil caution advised, consider lower alfentanil doses: combo may incr. alfentanil levels, risk of CNS and resp. depression, delayed recovery from alfentanil anesthesia (hepatic metab. inhibited) aripiprazole consider decr. aripiprazole dose 50%: combo may incr. aripiprazole levels (hepatic metab. inhibited) aspirin/caffeine monitor levels, decr. caffeine dose or limit caffeine consumption: combo may incr. caffeine levels, risk of cardiovascular and CNS stimulatory effects, toxicity (hepatic metab. inhibited) atomoxetine consider 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) bosutinib separate admin. by >2h: combo may decr. bosutinib levels, efficacy (absorption decreased at higher gastric pH) caffeine monitor 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] carbamazepine monitor levels: combo may incr. carbamazepine levels, risk of toxicity (hepatic metab. inhibited)

carmustine monitor CBC: combo may incr. risk of myelosuppression (mechanism unknown) citalopram max citalopram dose 20 mg/day: combo may incr. citalopram levels, risk of QT prolongation, cardiac arrhythmias, serotonin syndrome, other adverse effects (hepatic metab. inhibited) clobazam caution 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 combos monitor 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] cyclosporine monitor 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 disoproxil give 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) felodipine monitor BP: combo may incr. dihydropyridine levels, risk of hypotension, other calciumchannel blocker effects (hepatic metab. inhibited) fentanyl consider 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] isradipine monitor BP: combo may incr. dihydropyridine levels, risk of hypotension, other calciumchannel blocker effects (hepatic metab. inhibited) nicardipine monitor BP: combo may incr. dihydropyridine levels, risk of hypotension, other calciumchannel blocker effects (hepatic metab. inhibited) nifedipine monitor BP: combo may incr. dihydropyridine levels, risk of hypotension, other calciumchannel blocker effects (hepatic metab. inhibited) nilotinib separate admin. by at least several hours: combo may decr. nilotinib levels, efficacy (absorption decreased at higher pH)

nimodipine monitor BP: combo may incr. dihydropyridine levels, risk of hypotension, other calciumchannel blocker effects (hepatic metab. inhibited) nisoldipine monitor BP: combo may incr. dihydropyridine levels, risk of hypotension, other calciumchannel blocker effects (hepatic metab. inhibited) pemetrexed caution advised, monitor toxicity: combo may incr. levels of both drugs (renal excretion decr. by competition for active tubular transport) peppermint oil separate 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] phenytoins monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) [phenytoins: fosphenytoin, phenytoin] procainamide monitor levels: combo may incr. procainamide/NAPA levels, risk of toxicity (renal excretion decreased) rilpivirine give H2 blockers 12h before or 4h after rilpivirine: combo may decr. rilpivirine levels, efficacy (absorption decreased at higher gastric pH) sufentanil caution advised, consider lower sufentanil doses: combo may incr. risk of CNS and resp. depression, delayed recovery from sufentanil anesthesia (hepatic metab. inhibited) tacrolimus monitor levels: combo may incr. tacrolimus levels, risk of toxicity (hepatic metab. inhibited) theophyllines monitor levels: combo may incr. theophylline levels, risk of toxicity (hepatic metab. inhibited) [theophyllines: aminophylline, theophylline] valacyclovir caution advised, decr. valacyclovir dose only if renal impairment: combo may incr. valacyclovir levels (renal excretion decreased) valproic acid derivatives monitor levels: combo may incr. valproic acid levels, risk of toxicity (hepatic metab. inhibited) [valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid] vismodegib caution advised, consider D/C H2 blocker: combo may decr. vismodegib levels, efficacy (absorption decr. at higher gastric pH)

warfarin monitor INR: combo may incr. INR, risk of bleeding (hepatic metab. inhibited) zaleplon adjust zaleplon dose to 5 mg qhs: combo may incr. zaleplon levels, risk of adverse effects (hepatic metab. inhibited)

Therapeutic Advantage

digestive enzymes may 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

albendazole caution advised: combo may incr. albendazole levels, risk of toxicity (mechanism unknown) alendronate/cholecalciferol caution advised: combo may decr. cholecalciferol efficacy (hepatic metab. inhibited, decr. conversion to activated vitamin D) alfuzosin caution advised: combo may incr. alfuzosin levels, risk of adverse effects (hepatic metab. inhibited) alprazolam caution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) amiodarone caution advised: combo may incr. amiodarone levels, risk of toxicity (hepatic metab. possibly inhibited) atovaquone/proguanil caution advised: combo may decr. proguanil active metabolite levels, efficacy (hepatic metab. inhibited, decr. conversion to active metabolite) azelastine nasal caution advised: combo may incr. azelastine levels, risk of CNS depression, psychomotor impairment (hepatic metab. possibly inhibited) [azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal] bupropion caution advised: combo may incr. bupropion adverse effects (hepatic metab. inhibited) [bupropion: bupropion hydrobromide, bupropion hydrochloride] buspirone caution advised: combo may incr. buspirone levels, risk of adverse effects (hepatic metab. inhibited) capsicum caution 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 phosphate caution advised: combo may incr. chloroquine levels (hepatic metab. inhibited) clozapine caution advised: combo may incr. clozapine levels, risk of toxicity (hepatic metab. inhibited) crizotinib caution advised: combo may decr. crizotinib levels, efficacy (absorption decreased at higher gastric pH) dolasetron caution advised: combo may incr. dolasetron levels (hepatic metab. inhibited) duloxetine caution advised: combo may incr. duloxetine levels (hepatic metab. inhibited) dutasteride/tamsulosin caution advised: combo may incr. tamsulosin levels, risk of adverse effects (hepatic metab. inhibited) efavirenz/emtricitabine/tenofovir disoproxil caution advised: combo may incr. levels of tenofovir and cimetidine (renal excretion decr. by competition for active tubular transport) emtricitabine/tenofovir disoproxil caution 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] entecavir caution advised: combo may incr. levels of both drugs (renal excretion decr. by competition for active tubular transport) escitalopram caution advised: combo may incr. escitalopram levels, risk of adverse effects (hepatic metab. inhibited) ethanol caution advised: combo may incr. blood alcohol levels, risk of CNS depression, psychomotor impairment (absorption increased, gastric alcohol dehydrogenase inhibited) etravirine caution advised: combo may incr. etravirine levels, risk of adverse effects (hepatic metab. inhibited) flecainide caution advised: combo may incr. flecainide levels, risk of cardiac arrhythmias (hepatic metab. inhibited) fluvastatin caution advised: combo may incr. fluvastatin levels, risk of myopathy, rhabdomyolysis (mechanism unknown, absorption possibly altered)

fosamprenavir caution advised: combo may decr. amprenavir levels, efficacy (mechanism unknown) gefitinib caution advised: combo may decr. gefitinib levels, efficacy (absorption decreased at higher gastric pH) ginger caution 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] goldenseal caution 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 tea caution 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] guarana caution 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] lidocaine caution advised w/ systemic lidocaine: combo may incr. lidocaine levels, risk of adverse effects (mechanism unknown, hepatic metab. possibly inhibited) memantine caution advised: combo may incr. levels of both drugs (renal excretion decr. by competition for active tubular transport mechanism) meperidine caution advised: combo may incr. meperidine levels, risk of respiratory depression, other adverse effects (hepatic metab. inhibited) mepivacaine caution advised: combo may incr. risk of anesthetic toxicity (clearance decreased) methylphenidate caution 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] midazolam caution advised w/ oral midazolam: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

midodrine caution advised: combo may incr. levels of both drugs (renal excretion decr. by competition for active tubular transport mechanism) mycophenolic acid caution 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] olanzapine caution advised: combo may incr. olanzapine levels, risk of toxicity (hepatic metab. inhibited) olanzapine/fluoxetine caution advised: combo may incr. olanzapine levels, risk of toxicity (hepatic metab. inhibited) paroxetine caution advised: combo may incr. paroxetine levels, risk of adverse effects (hepatic metab. inhibited) pentamidine caution advised: combo may incr. pentamidine levels, risk of adverse effects, incl. QT prolongation, cardiac arrhythmias (hepatic metab. inhibited) pimozide caution advised: combo may incr. pimozide levels, risk of QT prolongation, cardiac arrhythmias (hepatic metab. inhibited) pramipexole caution advised: combo may incr. pramipexole levels, risk of adverse effects (renal excretion inhibited; renal excretion decr. by competition for active tubular transport) propafenone caution advised: combo may incr. propafenone levels, risk of adverse effects (hepatic metab. inhibited) quetiapine caution advised: combo may incr. quetiapine levels, risk of toxicity (hepatic metab. inhibited) ramelteon caution advised: combo may incr. ramelteon levels (hepatic metab. inhibited) red yeast caution 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] riluzole caution advised: combo may incr. riluzole levels, risk of adverse effects (hepatic metab. inhibited) roflumilast caution advised: combo may incr. roflumilast levels, risk of adverse effects (hepatic metab. inhibited)

sertraline caution advised: combo may incr. sertraline levels, risk of adverse effects (hepatic metab. inhibited) sildenafil caution advised: combo may incr. sildenafil levels, risk of adverse effects (hepatic metab. inhibited) sitagliptin caution advised: combo may incr. cimetidine levels, risk of adverse effects (renal excretion decr. by competition for active tubular transport mechanism) sitagliptin/simvastatin caution advised: combo may incr. levels of cimetidine and sitagliptin, risk of adverse effects (renal excretion decr. by competition for active tubular transport mechanism) tamoxifen caution advised: combo may decr. active tamoxifen metabolite levels, efficacy (hepatic metab. inhibited) tamsulosin caution advised: combo may incr. tamsulosin levels, risk of adverse effects (hepatic metab. inhibited) tenofovir disoproxil caution advised: combo may incr. levels of both drugs (renal excretion decr. by competition for active tubular transport) tetrabenazine caution advised: combo may incr. tetrabenazine active metabolite levels, risk of adverse effects (hepatic metab. inhibited) tramadol caution 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/acetaminophen caution 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) triazolam caution advised: combo may incr. triazolam levels, risk of CNS depression, psychomotor impairment (absorption increased at higher gastric pH) venlafaxine caution 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 Subclass H2 Blockers Related Subclasses Antacids H. pylor

Drug

Toradol
ketorolac

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/aspirin contraindicated 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/caffeine contraindicated 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) aspirin aspirin 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/caffeine aspirin 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 carbonate aspirin use contraindicated w/ ketorolac: combo may incr. risk of GI bleeding, adverse effects (additive effects) aspirin/chlorpheniramine/dextromethorphan aspirin 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/phenylephrine aspirin 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/phenylephrine aspirin 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/diphenhydramine aspirin 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/dipyridamole aspirin 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/phenylephrine aspirin 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/phenylephrine aspirin 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/aspirin aspirin 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) celecoxib contraindicated for ketorolac; avoid combo w/ other NSAIDs: combo may incr. risk of GI bleeding, adverse effects (additive effects, duplicate tx) cidofovir contraindicated, 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 combos aspirin 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 combos aspirin 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] pentoxifylline contraindicated for ketorolac, caution advised w/ other NSAIDs: combo may incr. risk of bleeding (additive effects) probenecid contraindicated for ketorolac; avoid combo w/ other NSAIDs: combo may incr. NSAID adverse effects (renal excretion decreased)

Avoid/Use Alternative

beta blocker/thiazide combos monitor 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, systemic monitor 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] danshen avoid 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 topical avoid 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 alfa weigh risk/benefit if NSAIDs w/in 7 days prior to drotrecogin alfa: combo may incr. risk of bleeding (additive effects) ethanol avoid or minimize alcohol use: combo may incr. risk of GI bleeding, gastritis (additive effects) fondaparinux weigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects) heparins weigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects) [heparins: dalteparin, enoxaparin, heparin, tinzaparin] hydrocodone/ibuprofen avoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased) ibritumomab tiuxetan weigh risk/benefit, monitor platelets: combo may incr. risk of bleeding (additive effects, ibritumomab induces severe prolonged thrombocytopenia) methotrexate avoid combo w/ high (anti-neoplastic) dose methotrexate, caution advised w/ low (antirheumatic) 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 acid avoid 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/esomeprazole avoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased) NSAID/chlorpheniramine/pseudoephedrine combos avoid 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 combos avoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased) [NSAID/diphenhydramine combos: ibuprofen/diphenhydramine] NSAID/phenylephrine combos avoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased) [NSAID/phenylephrine combos: ibuprofen/phenylephrine] NSAID/pseudoephedrine combos avoid 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] NSAIDs avoid 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/ibuprofen avoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased) pemetrexed avoid 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 sodium weigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)

sirolimus avoid combo; monitor renal fxn, BP, electrolytes: combo may incr. risk of nephrotoxicity, HTN, electrolyte abnormalities, edema, other adverse effects (additive/synergistic toxicity) sumatriptan/naproxen sodium avoid combo: combo may incr. risk of GI bleeding, nephrotoxicity, other adverse effects (duplicate tx; renal excretion decreased) tacrolimus avoid 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) warfarin weigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)

Monitor/Modify Tx

ACE inhibitor/thiazide combos monitor 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 inhibitors monitor 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/caffeine monitor renal fxn: combo w/ acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/caffeine/CNS depressant combos monitor 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/chlorpheniramine monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/chlorpheniramine/dextromethorphan monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/chlorpheniramine/dextromethorphan/phenylephrine monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/chlorpheniramine/phenylephrine monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/codeine monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/dextromethorphan monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/dextromethorphan/phenylephrine monitor 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/pseudoephedrine monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) [acetaminophen/dextromethorphan/pseudoephedrine: acetaminophen/dextromethorphan/pseudoephedrine/guaifenesin] acetaminophen/diphenhydramine monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/diphenhydramine/dextromethorphan monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/diphenhydramine/phenylephrine monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/doxylamine/dextromethorphan monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/doxylamine/dextromethorphan/phenylephrine monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/doxylamine/dextromethorphan/pseudoephedrine monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/doxylamine/phenylephrine monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown)

acetaminophen/magnesium salicylate/pamabrom monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/pamabrom monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/pheniramine/phenylephrine monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) acetaminophen/phenylephrine monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) [acetaminophen/phenylephrine: acetaminophen/phenylephrine, acetaminophen/phenylephrine/guaifenesin] acetaminophen/pseudoephedrine monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) [acetaminophen/pseudoephedrine: acetaminophen/pseudoephedrine/guaifenesin] acetaminophens monitor renal fxn: combo may incr. risk of nephrotoxicity (mechanism unknown) [acetaminophens: acetaminophen, acetaminophen rectal, acetaminophen/guaifenesin, isometheptene/dichloralphenazone/acetaminophen] adefovir dipivoxil caution advised, monitor renal fxn: combo may incr. adefovir levels, risk of nephrotoxicity (absorption increased) aliskiren monitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) aliskiren/amlodipine monitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) aliskiren/amlodipine/hydrochlorothiazide monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) aliskiren/hydrochlorothiazide monitor BP, renal fxn: combo may decr. antihypertensive, diuretic, and natriuretic efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) aliskiren/valsartan monitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) amlodipine/ARB combos monitor 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 combos monitor 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/benazepril monitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) ARB/thiazide combos monitor 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] ARBs monitor 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/acetaminophen monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) carbamazepine monitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects) chamomile, German caution 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] cyclosporine monitor 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] desmopressin monitor sodium: combo w/ NSAIDs may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects) [desmopressin: desmopressin, desmopressin nasal] desvenlafaxine caution 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-sparing caution 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] drospirenone monitor potassium: combo of NSAIDs and drospirenone may incr. risk of hyperkalemia (additive effects) [drospirenone: drospirenone/estradiol, drospirenone/ethinyl estradiol, drospirenone/ethinyl estradiol/levomefolate] duloxetine caution advised, monitor sodium: combo may incr. risk of bleeding, SIADH, hyponatremia (NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake; additive effects) eplerenone monitor BP, potassium: combo may decr. antihypertensive efficacy, incr. risk of severe hyperkalemia (antagonistic effects, additive effects) exenatide caution advised, monitor renal fxn: combo may incr. risk of nephrotoxicity (additive toxicity) hydralazine monitor BP: combo may decr. antihypertensive efficacy (antagonistic effects) hydrocodone/acetaminophen monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) isosorbide dinitrate/hydralazine monitor BP: combo may decr. antihypertensive efficacy (antagonistic effects) liraglutide caution advised, monitor renal fxn: combo may incr. risk of nephrotoxicity (additive toxicity) lithium monitor levels: combo may incr. lithium levels, risk of toxicity (renal excretion decreased) milnacipran caution advised, monitor sodium: combo may incr. risk of bleeding, SIADH, hyponatremia (NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake; additive effects) olanzapine/fluoxetine caution 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/acetaminophen monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) pamidronate monitor renal fxn: combo may incr. risk of nephrotoxicity (additive effects)

pentazocine/acetaminophen monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) polyethylene glycol/electrolytes monitor 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/acetaminophen monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) [propoxyphene/acetaminophen: propoxyphene hydrochloride/acetaminophen, propoxyphene napsylate/acetaminophen] red clover caution 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 phosphates monitor 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 sulfate caution advised; consider monitoring renal fxn, electrolytes: combo may incr. risk of fluid and electrolyte abnormalities (altered renal excretion) SSRIs, all caution 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] telavancin monitor renal fxn: combo may incr. risk of nephrotoxicity (additive effects) tramadol/acetaminophen monitor renal fxn: combo of NSAIDs and acetaminophen may incr. risk of nephrotoxicity (mechanism unknown) trandolapril/verapamil monitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) trazodone caution advised, monitor sodium: combo may incr. risk of bleeding, SIADH, hyponatremia (NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake; additive effects) venlafaxine caution advised, monitor sodium: combo may incr. risk of bleeding, SIADH, hyponatremia

(NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake; additive effects) zoledronic acid monitor renal fxn: combo may incr. risk of nephrotoxicity (additive effects)

Caution Advised

aldesleukin caution advised: combo may incr. risk of nephrotoxicity (additive toxicity) antiplatelets caution advised: combo may incr. risk of bleeding (additive effects) [antiplatelets: anagrelide, cilostazol, clopidogrel, dipyridamole, prasugrel, ticagrelor, ticlopidine] bisphosphonates, oral caution 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 cohosh caution 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] budesonide caution advised: combo may incr. risk of sodium and water retention, edema (additive effects) capsicum caution 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 histolyticum caution advised: combo may incr. risk of bleeding (additive effects) corticosteroids, systemic caution 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] darunavir caution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects) dasatinib caution advised: combo may incr. risk of bleeding (additive effects) deferasirox caution advised: combo may incr. risk of GI bleeding, adverse effects (additive effects)

desirudin caution advised: combo may incr. risk of bleeding (additive effects) diuretics, loop caution 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 combos caution 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, thiazide caution advised: combo may decr. diuretic, natriuretic, antihypertensive effects of thiazides (antagonistic effects) [diuretics, thiazide: chlorothiazide, chlorthalidone, clonidine/chlorthalidone, hydralazine/hydrochlorothiazide, hydrochlorothiazide, indapamide, methyclothiazide, metolazone] donepezil caution advised: combo may incr. risk of GI bleeding (additive effects) dong quai caution 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] erlotinib caution advised: combo w/ NSAIDs may incr. risk of GI bleeding, perforation (mechanism unknown, erlotinib may incr. INR) evening primrose oil caution 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] fenugreek caution 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 foenumgraecum] feverfew caution 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] flaxseed caution 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] galantamine caution advised: combo may incr. risk of GI bleeding (additive effects) garlic caution 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] ginger caution 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 biloba caution 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, Asian caution 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, Siberian caution 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 tea caution 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 seed caution 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/famotidine caution advised: combo may incr. NSAID adverse effects (duplicate tx) iloprost inhaled caution advised: combo may incr. risk of bleeding (additive antiplatelet effects) kava caution 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] leflunomide caution advised: combo may incr. NSAID adverse effects (hepatic metab. inhibited) licorice caution 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] neostigmine caution advised: combo may incr. risk of GI bleeding (additive effects) NSAIDs, ophthalmic caution advised: combo may incr. ocular bleeding risk postop (additive effects) [NSAIDs, ophthalmic: bromfenac ophthalmic, diclofenac ophthalmic, flurbiprofen ophthalmic, ketorolac ophthalmic, nepafenac ophthalmic] omega-3-acid caution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects) [omega-3-acid: omega-3-acid ethyl esters] platelet GP IIb/IIIa inhibitors caution advised: combo may incr. risk of bleeding (additive effects) [platelet GP IIb/IIIa inhibitors: abciximab, eptifibatide, tirofiban] porfimer caution advised: combo may decr. efficacy of photodynamic tx; antiplatelet agents may decr. thromboxane A2-mediated tumor necrosis (antagonistic effects) pralatrexate caution advised: combo may incr. pralatrexate levels, risk of toxicity (renal excretion decreased) pyridostigmine caution advised: combo may incr. risk of GI bleeding (additive effects) quinolones, all caution advised: combo may incr. risk of CNS stimulation, seizures (mechanism unknown) [quinolones, all: ciprofloxacin, gemifloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin] rivaroxaban caution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects) rivastigmine caution advised: combo may incr. risk of GI bleeding (additive effects) [rivastigmine: rivastigmine, rivastigmine transdermal] sibutramine caution advised: combo may incr. risk of bleeding (synergistic effects, NSAID antiplatelet effects augmented by inhibition of platelet serotonin uptake) tacrine caution advised: combo may incr. risk of GI bleeding (additive effects)

thrombin inhibitors caution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects) [thrombin inhibitors: antithrombin (recombinant), antithrombin III, argatroban, dabigatran, lepirudin] thrombolytics caution advised: combo may incr. risk of bleeding (additive effects) [thrombolytics: alteplase, reteplase, tenecteplase] tipranavir caution advised: combo may incr. risk of bleeding (additive antiplatelet effects) treprostinil caution advised: combo may incr. risk of bleeding (additive antiplatelet effects) [treprostinil: treprostinil, treprostinil inhaled] valproic acid derivatives caution advised: combo may incr. risk of bleeding, valproic acid exerts antiplatelet effects (additive effects) [valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid] willow bark caution 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 Genrico: ketorolac Nombres de las Marcas: Toradol, Toradol IM, Toradol IV/IM

Cul es la informacin ms importante que debo saber sobre ketorolac?

Esta medicina puede aumentar su riesgo de problemas al corazn o de la circulacin que pongan su vida en peligro, que incluyen ataques al corazn o accidentes cerebrovasculares. No use esta medicina justo antes o despus de tener una ciruga de bypass arterial coronario con injerto (tambin conocida como CABG (por sus siglas en Ingls)).

Busque atencin mdica de emergencia si nota sntomas de problemas del corazn o de la circulacin, como dolor de pecho, debilidad, falta de aire al respirar, o problemas de la visin o del balance. Esta medicina tambin puede aumentar su riesgo a tener efectos secundarios graves del estmago o intestinos, que incluye sangrado o perforacin (formacin de hueco). Estas condiciones pueden causar la muerte y los efectos secundarios gastrointestinales pueden ocurrir en cualquier momento sin ninguna advertencia mientras est tomando ketorolac. Los ancianos pueden estar a ms riesgo de los efectos secundarios graves gastrointestinales. Hable de inmediato con su mdico si nota sntomas de sangrado del estmago o intestinos. Esto incluye heces fecales negras, con sangre, o color de arcilla, o sangre al toser, o vmito que tiene apariencia a caf molido.

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

Qu es ketorolac?
Ketorolac pertenece al grupo de drogas denominadas drogas antiinflamatorias no esteroides (AINES). Ketorolac funciona reduciendo las hormonas que causan inflamacin y dolor en el cuerpo. Ketorolac se usa por tiempo limitado (5 das o menos) para el tratamiento del dolor moderado a severo. Ketorolac puede tambin usarse para propsitos diferentes a los que estn incluidos en esta gua del medicamento.

Qu debera 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 rin; problema de sangrado o cogulos de sangre; una herida interna de la cabeza o sangrado cerebral; historial de lcera del estmago o sangrado intestinal; o si le est dando de lactar al beb.

No tome ketorolac si tambin est 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 corazn o de la circulacin que pongan su vida en peligro, que puede incluir ataques del corazn o accidentes cerebrovasculares. Este riesgo aumentar con el uso prolongado de ketorolac. No use esta medicina inmediatamente antes o despus de tener una ciruga de bypass arterial coronario con injerto (tambin conocida como CABG (por sus siglas en Ingls)). Los AINES (NSAIDs, por sus siglas en Ingls) tambin pueden aumentar su riesgo de tener efectos secundarios de gravedad del estmago o intestinos, que incluyen sangrado o perforacin (formacin de hueco). Estas condiciones pueden causar la muerte y los efectos gastrointestinales pueden ocurrir sin ninguna advertencia en cualquier momento mientras est 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, dgale a su mdico si usted tiene alergia a alguna droga, o si tiene:

historial de ataque al corazn, accidente cerebrovascular, o cogulos de sangre; enfermedad del corazn, falla cardaca congestiva, presin arterial alta; enfermedad del hgado o del rin, colitis ulcerosa o enfermedad de Crohn; asma; plipos en su nariz; si usted recientemente tuvo una ciruga; o si fuma.

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

Clasificado por la FDA en la categora C de riesgos a la gestacin. Esta medicina le puede hacer dao al beb nonato. El uso de ketorolac durante el trabajo de parto puede aumentar el riesgo de sangrar durante el nacimiento del beb. No tome ketorolac durante el embarazo a menos que su mdico se lo indique hacerlo. Esta medicina puede afectar su fertilidad (la habilidad de poder tener bebs). No tome Ketorolac mientras est tratando de concebir.

Ketorolac pasa a la leche materna y puede hacerle dao al beb lactante. No use Ketorolac sin antes hablar con su mdico si le est dando de lactar al beb.

No le d esta medicina a personas menores de 18 aos.

Cmo debo tomar ketorolac?

Tome esta medicina exactamente como se lo hayan recetado. No tome la medicina en cantidades mayores o por ms tiempo de lo recomendado por su mdico. Siga las instrucciones que vienen con su receta. Ketorolac no se usa para el tratamiento de dolores menores. Ketorolac es usualmente usado primero en inyeccin y despus en tableta. Ketorolac inyeccin se aplica mediante una jeringa en el msculo o en la vena. Su mdico, enfermera, u otro profesional de la salud le aplicar esta inyeccin.

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

Ketorolac por lo general se administra por 5 das o menos, considerndose el total combinado de inyeccin o de forma oral. El uso prolongado de ketorolac puede hacerle dao a los riones o causar sangrado.

Si necesita someterse a algn tipo de ciruga, dgale al cirujano por adelantado si usted ha usado ketorolac recientemente.

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

Qu 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 inyeccin de ketorolac en el hospital o lugar similar, no se considera probable que se salte una dosis. Si est tomando la medicina con regularidad, tome la dosis pasada tan pronto se acuerde. Si ya es hora para su prxima dosis, espere y tome la medicina en su prximo horario regular. No tome ms medicina para alcanzar la dosis pasada.

Qu sucede si tomo una sobredosis?

Busque atencin medica de emergencia si sospecha que ha usado demasiado de esta medicina. Los sntomas de una sobredosis puede incluir nusea, vmito, dolor de estmago, adormecimiento, heces fecales negras o con sangre, tos con sangre, respiracin no profunda, y desmayo.

Qu 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 mdico o farmacutico. 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 podra tomar, sin intencin, 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 est tomando ketorolac. El alcohol puede aumentar el riesgo de sangrado del estmago que causa ketorolac.

Cules son los efectos secundarios posibles de ketorolac?

Busque atencin medica de emergencia si usted nota alguna de estos sntomas de una reaccin alrgica: ronchas; dificultad al respirar; hinchazn de la cara, labios, lengua, o garganta.

Deje de tomar ketorolac y busque atencin medica o hable de inmediato con su mdico 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 visin o el balance; heces fecales negras, con sangre, o alquitranadas; toser sangre o vmito que parece caf molido; hinchazn o ganancia rpida de peso; orinar menos de lo normal o nada; nusea, dolor de estmago, 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 seal 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, escalofros, aumento de sensibilidad a luz, puntos morados en la piel, o convulsiones.

Efectos secundarios de menor gravedad pueden incluir:

malestar estomacal, nusea o vmito leve, diarrea, estreimiento; acidez leve, dolor del estmago, hinchazn, gas; mareos, nerviosismo, dolor de cabeza; sudoracin; o zumbido en los odos.

Esta lista no menciona todos los efectos secundarios y puede ser que ocurran otros. Dgale a su mdico 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.

Qu otras drogas afectarn a ketorolac?

Dgale a su mdico si est 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 fcilmente. Antes de tomar ketorolac, dgale a su mdico si usted est tomando:

anticoagulante como warfarin (Coumadin); lithium (Eskalith, Lithobid); methotrexate (Rheumatrex, Trexall); thiothixene (Navane); alprazolam (Xanax); diurticos (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 corazn 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. Dgale a su mdico acerca de todas las medicinas que est tomando, ya sean recetadas o no. Estas deben incluir vitaminas, minerales, productos herbarios, y las drogas recetadas por otros mdicos. No empiece a usar una nueva medicina sin primero decirle a su mdico.

Dnde puedo obtener ms informacin?

Su farmacutico tiene ms informacin acerca de ketorolac.

Drug

Lasix
furosemide

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

aminoglycosides, parenteral avoid combo or monitor closely: combo may incr. risk of ototoxicity, nephrotoxicity (additive toxicity) [aminoglycosides, parenteral: amikacin, gentamicin, kanamycin, streptomycin, tobramycin] lithium avoid combo or monitor levels closely: combo may incr. lithium levels, risk of toxicity (renal excretion decreased)

Monitor/Modify Tx

ACE inhibitor/thiazide combos monitor 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 inhibitors monitor 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/aspirin caution 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/caffeine caution 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/pamabrom caution 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/hydrochlorothiazide monitor 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/hydrochlorothiazide monitor 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) amifostine caution advised, monitor BP: combo may incr. risk of hypotension (additive effects)

amlodipine/ARB combos monitor 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 combos monitor 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/benazepril monitor BP, use for therapeutic advantage: combo may incr. risk of hypotension (synergistic effects) amphotericins monitor 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 III monitor 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 combos monitor 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] ARBs monitor BP, use for therapeutic advantage: combo may incr. risk of hypotension (synergistic effects) [ARBs: azilsartan, candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan] arsenic trioxide monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) artemether/lumefantrine monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) asenapine monitor potassium, BP: combo may incr. risk of QT prolongation, cardiac arrhythmias, hypotension (hypokalemia, other electrolyte abnormalities, additive effects) aspirin/caffeine caution 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 carbonate caution 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/dextromethorphan caution 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/phenylephrine caution 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/phenylephrine caution 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/diphenhydramine caution 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/phenylephrine caution 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/phenylephrine caution 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, all monitor 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 combos monitor 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 subsalicylate caution 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/tetracycline caution 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, injectable caution advised, monitor calcium: loop diuretics may cause incr. urinary excretion of calcium, incr. risk of hypocalcemia (additive hypocalcemic effects) [bisphosphonates, injectable: pamidronate, zoledronic acid] budesonide monitor potassium: combo may incr. risk of hypokalemia (additive effects) calcium channel blockers, others monitor BP, use for therapeutic advantage: combo may incr. risk of hypotension (synergistic effects) [calcium channel blockers, others: diltiazem, trandolapril/verapamil, verapamil] carbonic anhydrase inhibitors, systemic monitor potassium, electrolytes: combo may incr. risk of hypokalemia, other electrolyte abnormalities (additive effects) [carbonic anhydrase inhibitors, systemic: acetazolamide, methazolamide] carboplatin monitor renal fxn, electrolytes: combo may incr. risk of ototoxicity, electrolyte abnormalities (overlapping toxicity, additive effects) cisapride monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) cisplatin monitor renal fxn, electrolytes: combo may incr. risk of ototoxicity, electrolyte abnormalities (overlapping toxicity, synergistic effects) clarithromycin monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) CNS depressant/aspirin/caffeine combos caution 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, systemic monitor 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] crizotinib monitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) dasatinib monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) deferiprone monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) degarelix monitor 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) desvenlafaxine monitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects) dexlansoprazole monitor magnesium: combo may incr. risk of hypomagnesemia (additive effects) dextromethorphan/quinidine monitor potassium: combo w/ quinidine may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) diazoxide monitor BP, glucose, uric acid levels: combo may incr. diazoxide hyperglycemic, hyperuricemic, antihypertensive effects (synergistic effects) digoxin monitor potassium: loop diuretics may cause hypokalemia, incr. risk of digoxin toxicity (hypokalemia, other electrolyte abnormalities) diuretics, potassium-sparing/thiazide combos monitor 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, thiazide monitor 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] dolasetron monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

dronedarone monitor potassium, electrolytes: combo may incr. risk of hypokalemia, QT prolongation, cardiac arrhythmias (additive effects, hypokalemia, other electrolyte abnormalities) droperidol caution advised, monitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) duloxetine monitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects) ephedra monitor 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] ephedrine monitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) [ephedrine: ephedrine, ephedrine/guaifenesin] erythromycins monitor 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] esomeprazole monitor magnesium: combo may incr. risk of hypomagnesemia (additive effects) exenatide monitor renal fxn, glucose: combo may incr. risk of nephrotoxicity; may decr. hypoglycemic agent efficacy (additive toxicity; antagonistic effects, loop diuretics may cause hyperglycemia) ezogabine monitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia) fingolimod monitor ECG overnight and monitor potassium when starting or restarting fingolimod tx: combo may incr. risk of QT prolongation, cardiac arrhythmias (additive effects, hypokalemia) GnRH agonists monitor 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] haloperidol monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) [haloperidol: haloperidol, haloperidol decanoate, haloperidol lactate]

hypoglycemics, other monitor 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] iloperidone monitor potassium, BP: combo may incr. risk of QT prolongation, cardiac arrhythmias, hypotension (hypokalemia, other electrolyte abnormalities, additive effects) insulins monitor 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] isoproterenol monitor potassium: combo may incr. risk of hypokalemia (additive effects) lansoprazole monitor magnesium: combo may incr. risk of hypomagnesemia (additive effects) lansoprazole/amoxicillin/clarithromycin monitor 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) lapatinib monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) linagliptin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects) linagliptin/metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, loop diuretics may cause hyperglycemia) liraglutide monitor renal fxn, glucose: combo may incr. risk of nephrotoxicity; may decr. hypoglycemic agent efficacy (additive toxicity; antagonistic effects, loop diuretics may cause hyperglycemia) lopinavir/ritonavir monitor potassium, electrolytes: combo may incr. risk of QT interval prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) lurasidone monitor BP: combo may incr. risk of hypotension (additive effects) metformin/sulfonylurea combos monitor glucose: combo may decr. hypoglycemic agent efficacy; loop diuretics may cause hyperglycemia (antagonistic effects) [metformin/sulfonylurea combos: glipizide/metformin, glyburide/metformin] methadone monitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

mifepristone monitor potassium if daily mifepristone use: combo may incr. risk of hypokalemia, QT prolongation, cardiac arrhythmias (additive effects) milnacipran monitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects) naproxen/esomeprazole caution 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) nesiritide monitor BP: combo may incr. risk of hypotension (additive/synergistic effects) nilotinib monitor potassium, electrolytes: combo may incr. risk of hypokalemia, QT prolongation, cardiac arrhythmias (additive effects, hypokalemia, other electrolyte abnormalities) NSAID/chlorpheniramine/pseudoephedrine combos monitor 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 combos monitor 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 combos monitor 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 combos monitor 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] octreotide monitor fluid and electrolytes; consider lower diuretic dose: combo may alter diuretic requirements, incr. risk of electrolyte abnormalities (additive effects, antagonistic effects) omeprazole monitor magnesium: combo may incr. risk of hypomagnesemia (additive effects) [omeprazole: omeprazole, omeprazole/sodium bicarbonate] omeprazole/clarithromycin/amoxicillin monitor 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) ondansetron monitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

oprelvekin monitor fluid and electrolytes w/ chronic diuretic tx: combo may incr. risk of severe hypokalemia (mechanism unknown) paliperidone monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) [paliperidone: paliperidone, paliperidone palmitate] pantoprazole monitor magnesium: combo may incr. risk of hypomagnesemia (additive effects) pentamidine monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) phenothiazines monitor 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] pimozide monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) polyethylene glycol/electrolytes monitor 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/codeine monitor potassium, electrolytes: combo of loop diuretics w/ phenothiazines may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) propafenone monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) quetiapine monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) quinine sulfate monitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) quinolones, QT prolongers monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) [quinolones, QT prolongers: gemifloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin] rabeprazole monitor magnesium: combo may incr. risk of hypomagnesemia (additive effects)

ranolazine monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) salicylates caution 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] saquinavir monitor potassium, electrolytes: combo may incr. risk of hypokalemia, QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) saxagliptin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, loop diuretics may cause hyperglycemia) saxagliptin/metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, loop diuretics may cause hyperglycemia) sitagliptin monitor glucose: combo may decr. hypoglycemic agent efficacy; loop diuretics may cause hyperglycemia (antagonistic effects) sitagliptin/simvastatin monitor glucose: combo may decr. hypoglycemic agent efficacy; loop diuretics may cause hyperglycemia (antagonistic effects) sodium phosphates monitor 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 sulfate monitor renal fxn, electrolytes: combo may incr. risk of nephrotoxicity, seizures, QT prolongation, cardiac arrhythmias (additive effects, electrolyte abnormalities) SSRIs, all monitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects) [SSRIs, all: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, vilazodone] sulfonylureas monitor glucose: combo may decr. sulfonylurea efficacy, loop diuretics may cause hyperglycemia (antagonistic effects) [sulfonylureas: chlorpropamide, glimepiride, glipizide, glyburide, glyburide micronized, tolazamide, tolbutamide] sunitinib monitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

telavancin monitor potassium, electrolytes, renal fxn: combo may incr. risk of QT prolongation, cardiac arrhythmias, nephrotoxicity (hypokalemia, other electrolyte abnormalities, additive effects) telithromycin monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) tetrabenazine monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) thiazolidinediones monitor 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] tizanidine caution advised, monitor BP: combo may incr. risk of hypotension (additive effects) toremifene monitor potassium, electrolytes: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities) trazodone monitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects) venlafaxine monitor sodium: combo may incr. risk of SIADH, hyponatremia, other adverse effects (additive effects) ziprasidone caution advised, monitor potassium: combo may incr. risk of QT prolongation, cardiac arrhythmias (hypokalemia, other electrolyte abnormalities)

Caution Advised

aldesleukin caution advised: combo may incr. risk of hypotension (additive effects) aliskiren caution advised: combo may decr. furosemide levels, efficacy (mechanism unknown) aliskiren/amlodipine caution advised: combo may decr. furosemide levels, efficacy (mechanism unknown) aliskiren/valsartan consider alternatives; monitor BP, use for therapeutic advantage: combo may decr. furosemide levels, efficacy; may incr. risk of hypotension (mechanism unknown; synergistic effects) allopurinol caution advised: combo may decr. hypouricemic efficacy (antagonistic effects)

apomorphine caution advised: combo may incr. risk of orthostatic hypotension, MI, pneumonia, falls, other apomorphine adverse effects (additive effects) celecoxib caution advised: combo may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects) diclofenac topical caution 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] febuxostat caution advised: combo may decr. hypouricemic efficacy (antagonistic effects) ginseng, Asian caution 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/ibuprofen caution advised: combo may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects) ibuprofen/famotidine caution advised: combo w/ ibuprofen may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects; additive effects) iloprost inhaled caution advised: combo may incr. risk of hypotension (additive/synergistic effects) licorice caution 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-selective caution advised: combo may incr. risk of hypotension (additive effects) [MAOIs, non-selective: isocarboxazid, phenelzine, procarbazine, selegiline transdermal, tranylcypromine] maraviroc caution 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 thiosulfate caution advised: combo w/ nitrites may incr. risk of hypotension (additive effects) [nitrites/sodium thiosulfate: amyl nitrite/sodium nitrite/sodium thiosulfate, sodium nitrite/sodium thiosulfate]

NSAIDs caution 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/ibuprofen caution advised: combo may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects) pegloticase caution advised: combo may decr. hypouricemic efficacy (antagonistic effects) probenecid caution advised: combo may decr. hypouricemic efficacy (antagonistic effects) sildenafil caution advised: combo may incr. risk of symptomatic hypotension (additive effects) sumatriptan/naproxen sodium caution advised: combo w/ NSAIDs may decr. diuretic, natriuretic, antihypertensive effects of loop diuretics, incr. risk of nephrotoxicity (antagonistic effects, additive effects) tadalafil caution advised: combo may incr. risk of hypotension (additive effects) treprostinil caution 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 Action inhibits 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 Genrico: furosemide Nombre de la Marca: Lasix

Cul es la informacin ms importante que debo saber sobre furosemide?

No use esta medicina si usted no puede orinar. Antes de usar esta medicamento, dgale a su mdico si usted tiene enfermedad del rin, prstata agrandada, problemas urinarios, cirrosis u otra enfermedad del hgado, un desequilibrio de electrlitos, colesterol elevado, la gota, lupus, diabetes, o una alergia a las drogas sulfa.

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

No tome ms medicamento de lo recetado. Dosis altas de furosemide pueden causar una perdida de audicin irreversible. Furosemide har que usted orine con ms frecuencia y puede hacer que se deshidrate muy fcilmente. Siga las instrucciones de su mdico acerca del uso de suplementos de potasio o de tener suficiente sal y potasio en su dieta.

Evite deshidratarse. Evite la exposicin a la luz solar o camas para broncearse. Sigas las instrucciones de su mdico acerca del tipo y la cantidad de lquidos que usted debe tomar mientras est tomando furosemide.

Para estar seguro de que este medicamento no le est haciendo dao, habr que examinar su sangre con frecuencia. Su funcin de su rin puede tambin necesitar ser examinado. Visite a su mdico con regularidad.

Si usted est recibiendo tratamiento para la presin arterial alta, siga usando esta medicina aunque se sienta bien. La presin arterial alta frecuentemente no tiene sntomas.

Qu es furosemide?
Furosemide es un diurtico del asa (pastilla para excrecin 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 retencin de lquidos acuoso (edema) en las personas con fallo cardaco congestivo, enfermedad del hgado, o problemas del rin como el sndrome nefrtico. Esta medicina tambin se usa para el tratamiento de la presin arterial elevada (hipertensin). Furosemide puede tambin usarse para fines no mencionados en esta gua del medicamento.

Qu debera 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, dgale a su mdico si usted tiene cualquiera de estas otras condiciones:

enfermedad del rin; prstata agrandada, obstruccin de la vejiga u otros problemas urinarios; cirrosis u otra enfermedad del hgado; desequilibrio de electrlitos (como niveles bajos de potasio o magnesio en su sangre); colesterol o triglicridos elevados (un tipo de grasa en la sangre); gota; lupus; diabetes; o una alergia a sulfa drogas.

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

Categora C del embarazo por la FDA. No se conoce si furosemide causar dao al beb nonato. Dgale a su mdico si usted est embarazada o planea quedar embarazada mientras est usando este medicamento.

Furosemide puede pasar a la leche materna y le puede hacer dao al beb nonato. Este medicamento puede tambin retrasar la produccin de leche materna. No use esta medicina sin primero hablar con su mdico si usted le est dando de lactar al beb.

Cmo debo tomar furosemide?

Tmelo exactamente como lo haya recetado su mdico. No lo tome en cantidades mayores o menores, o por ms tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripcin.

No tome ms medicamento de lo recetado. Dosis altas de furosemide pueden causar una perdida de audicin irreversible. Tal vez su mdico en ocasiones cambie su dosis para asegurarse de que est obteniendo los mejores resultados.

Mida la medicina lquida con una cucharita o taza de medicin, no lo haga con una cuchara normal. Si no tiene con qu medir su medicina, pdale una a su farmacutico. Furosemide har que usted orine con ms frecuencia y puede hacer que se deshidrate muy fcilmente. Siga las instrucciones de su mdico 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 est haciendo dao, habr que examinar su sangre con frecuencia. Su funcin de su rin puede tambin necesitar ser examinado. Visite a su mdico con regularidad.

Si usted est recibiendo tratamiento para la presin arterial alta, siga usando esta medicina aunque se sienta bien. La presin arterial alta frecuentemente no tiene sntomas.

Guarde a temperatura ambiente fuera de la humedad, el calor, y la luz. La medicina lquida de furosemide debe ser usada dentro de 60 a 90 das despus de abrir la botella. Pregntele a su farmacutico por cuntos das su medicina est en buen estado. Bote cualquier lquido que no haya usado despus de que ese tiempo haya pasado.

Qu sucede si me salto una dosis?

Furosemide a veces se usa solamente una vez, y tal vez no necesite mantener un horario regular. Si est usando esta medicina en un horario regular, tome la dosis pasada tan pronto se acuerde. Sltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome ms medicina para alcanzar la dosis pasada.

Qu sucede si tomo una sobredosis?

Busque atencin mdica de emergencia o llame a la lnea de Poison Help al 1-800-222-1222. Los sntomas de una sobredosis pueden incluir zumbido en los odos, perdida del apetito, debilidad, mareo, confusin, sensacin de mareado, o desmayo.

Qu debo evitar mientras tomo furosemide?

Evite levantarse muy rpido de la posicin de sentado o acostado, ya que puede sentirse mareado. Levntese despacio y estabilcese para evitar que se caiga.

Evite deshidratarse. Sigas las instrucciones de su mdico acerca del tipo y la cantidad de lquidos que usted debe tomar mientras est tomando furosemide.

Evite la exposicin a la luz solar o camas para broncearse. Furosemide puede hacer que se queme ms fcilmente. Pngase ropa que lo proteja y use un bloqueador con filtro solar (de SPF 30 o mayor) si usted est afuera.

Cules son los posibles efectos secundarios de furosemide?

Busque atencin medica de emergencia si usted tiene alguno de estos sntomas de una reaccin alrgica: ronchas, dificultad para respirar, hinchazn de la cara, labios, lengua, o garganta.

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

zumbido en sus odos, perdida de la audicin; sentirse muy sediento o caliente, sudar fuertemente, o piel caliente y seca; orinar con dolor o dificultad; fiebre, glndulas hinchadas, dolor de cuerpo, sntomas de la gripe; sarpullido, moretones o sangrado fcil, hormigueo severo, dolor, entumecimiento o debilidad repentina; dolor de pecho, ritmo cardaco irregular, tos nueva o que empeora con fiebre, dificultad para respirar; confusin, vmito, hinchazn, ganancia de peso rpida, orinar menos de lo usual o nada en absoluto; piel plida, 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 cardaco rpido, dificultad para concentrarse; nusea, dolor en la parte superior del estmago, picazn, prdida 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, confusin, aumento de querer orinar, dolor o debilidad musculares, desmayo, o convulsiones; entumecimiento o sensacin de hormigueo alrededor su boca, opresin o contraccin del msculo, reflejos hiperactivos; dolor de cabeza, prdida del apetito, sensacin de inestabilidad, respiracin superficial o respiracin que se detiene; o reaccin severa de la piel -- fiebre, dolor de garganta, hinchazn en su cara o lengua, quemazn en sus ojos, dolor de la piel, seguido por un sarpullido rojo o prpura que se extiende (especialmente en la cara o la parte superior del cuerpo) y causa ampollas y descamacin.

Efectos secundarios de menor gravedad pueden incluir:

diarrea, estreimiento, dolor de estmago; mareo, sensacin de girar; visin borrosa; o picazn o sarpullido leves.

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

Qu otras drogas afectarn a furosemide?

Si usted toma sucralfate (Carafate), tmelo por lo menos 2 horas antes o despus de tomar furosemide. Dgale a su mdico 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 cncer (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 antibitico como cefdinir (Omnicef), cefprozil (Cefzil), cefuroxime (Ceftin), cephalexin (Keflex), y otras; un antibitico como amikacin (Amikin), gentamicin (Garamycin), kanamycin (Kantrex), neomycin (Mycifradin, Neo Fradin, Neo Tab), paromycin (Humatin, Paromycin), streptomycin, tobramycin (Nebcin, Tobi); medicamento para el corazn o la presin 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. Dgale a su mdico 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 mdico.

Dnde puedo obtener ms informacin?

Su farmacutico le puede dar ms informacin acerca de furosemide.

Drug

Dilantin
phenytoin

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), 1020 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

boceprevir contraindicated: combo may decr. boceprevir levels, efficacy (hepatic metab. induced) delavirdine contraindicated: combo may decr. delavirdine levels, efficacy (hepatic metab. induced) emtricitabine/rilpivirine/tenofovir disoproxil contraindicated: combo may decr. rilpivirine levels, efficacy (hepatic metab. induced) etravirine contraindicated: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) lopinavir/ritonavir contraindicated 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) lurasidone contraindicated: combo may decr. lurasidone levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) praziquantel contraindicated; 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) ranolazine contraindicated: combo may decr. ranolazine levels, efficacy (hepatic metab. induced) rilpivirine contraindicated: combo may decr. rilpivirine levels, efficacy (hepatic metab. induced)

Avoid/Use Alternative

acetaminophen/codeine use 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) axitinib avoid combo: combo may decr. axitinib levels, efficacy (hepatic metab. induced) bortezomib avoid combo: combo may decr. bortezomib levels, efficacy (hepatic metab. induced) bosutinib avoid combo: combo may decr. bosutinib levels, efficacy (hepatic metab. induced) cabazitaxel avoid combo: combo may decr. cabazitaxel levels, efficacy (hepatic metab. induced) calcium channel blockers, dihydropyridines use 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, others use alternative or monitor for efficacy: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced) [calcium channel blockers, others: diltiazem, trandolapril/verapamil, verapamil] cobicistat avoid combo: combo may decr. cobicistat levels, efficacy (hepatic metab. induced) [cobicistat: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil] contraceptives, oral combo caution 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 progestin use additional non-hormonal or alternative contraception: combo may decr. hormonal

contraceptive levels, efficacy (hepatic metab. induced) [contraceptives, oral progestin: norethindrone] contraceptives, other combo caution 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] crizotinib avoid combo or use alternative: combo may decr. crizotinib levels, efficacy (hepatic metab. induced) deferasirox avoid 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) dopamine use alternative or monitor BP: combo w/ IV phenytoins may incr. risk of severe hypotension (mechanism unknown, possible additive effects) dronedarone avoid combo: combo may decr. dronedarone levels, efficacy (hepatic metab. induced) elvitegravir avoid combo or use alternative: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) [elvitegravir: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil] enzalutamide avoid combo: combo may decr. levels of both drugs, efficacy (hepatic metab. induced) erlotinib use alternative or consider incr. erlotinib dose >150 mg/day: combo may decr. erlotinib levels (hepatic metab. induced) etonogestrel subdermal implant use additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) everolimus avoid 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 biloba avoid 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/acetaminophen use 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) irinotecan avoid 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) ivacaftor avoid combo: combo may decr. ivacaftor levels, efficacy (hepatic metab. induced) ixabepilone use alternative: combo may decr. ixabepilone levels, efficacy (hepatic metab. induced) lapatinib avoid 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) levonorgestrel use alternative non-hormonal contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) linagliptin use alternative: combo may decr. linagliptin levels, efficacy (hepatic metab. induced, pglycoprotein induced, antagonistic effects) linagliptin/metformin use alternative: combo may decr. linagliptin levels, efficacy (hepatic metab. induced, Pglycoprotein induced) local anesthetics avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) [local anesthetics: bupivacaine, bupivacaine liposomal, chloroprocaine, lidocaine, mepivacaine, procaine, ropivacaine] local anesthetics/epinephrine avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) [local anesthetics/epinephrine: articaine/epinephrine] medroxyprogesterone acetate use additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) methotrexate use alternative or monitor efficacy, toxicity, levels: combo may incr. methotrexate toxicity and decr. efficacy; may decr. phenytoin levels, efficacy (mechanism unknown; absorption decreased) mifepristone avoid combo if daily mifepristone use; caution advised if pregnancy termination use: combo may decr. mifepristone levels, efficacy (hepatic metab. induced) milk thistle avoid 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] nilotinib avoid 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/acetaminophen use 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) pazopanib contraindicated if chronic use of strong CYP3A4 inducer, otherwise avoid combo or use alternative: combo may decr. pazopanib levels, efficacy (hepatic metab. induced) pentazocine/acetaminophen use 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) posaconazole weigh risk/benefit, monitor phenytoin levels: combo may decr. posaconazole levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. altered) rivaroxaban avoid combo: combo may decr. rivaroxaban levels, efficacy (hepatic metab. induced, Pglycoprotein induced) roflumilast avoid combo: combo may decr. roflumilast levels, efficacy (hepatic metab. induced) sunitinib use 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) tadalafil avoid combo in pulmonary HTN pts; caution advised for ED pts: combo may decr. tadalafil levels, efficacy (hepatic metab. induced) telaprevir avoid 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) temsirolimus avoid combo or consider incr. temsirolimus dose to 50 mg/wk: combo may decr. temsirolimus and sirolimus levels, efficacy (hepatic metab. induced) ticagrelor avoid combo: combo may decr. ticagrelor levels, efficacy (hepatic metab. induced) tolvaptan avoid combo or consider incr. tolvaptan dose: combo may decr. tolvaptan levels, efficacy (hepatic metab. induced)

tramadol avoid 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/acetaminophen use 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) ulipristal use alternative non-hormonal contraception: combo may decr. ulipristal levels, contraceptive efficacy (hepatic metab. induced) vandetanib avoid combo: combo may decr. vandetanib levels, efficacy (hepatic metab. induced)

Monitor/Modify Tx

acarbose monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) acetaminophen/aspirin caution 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/caffeine caution 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/caffeine caution 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 combos caution 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/chlorpheniramine caution 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 caution 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/phenylephrine caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation) acetaminophen/chlorpheniramine/phenylephrine caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation) acetaminophen/dextromethorphan caution 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 caution 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/pseudoephedrine caution 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/diphenhydramine caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation) acetaminophen/diphenhydramine/dextromethorphan caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation) acetaminophen/diphenhydramine/phenylephrine caution 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 caution 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/phenylephrine caution 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/pseudoephedrine caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation) acetaminophen/doxylamine/phenylephrine caution 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/pamabrom caution 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/pamabrom caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced, incr. toxic metabolite formation) acetaminophen/pheniramine/phenylephrine caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation) acetaminophen/phenylephrine caution 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/pseudoephedrine caution 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] acetaminophens caution 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] acyclovir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown) aliskiren/amlodipine monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced) aliskiren/amlodipine/hydrochlorothiazide monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced) amiodarone monitor levels, efficacy: combo may incr. phenytoin levels, risk of toxicity; decr. amiodarone levels, efficacy (hepatic metab. inhibited; hepatic metab. induced) amlodipine/ARB combos monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced) [amlodipine/ARB combos: amlodipine/olmesartan, amlodipine/valsartan, telmisartan/amlodipine] amlodipine/ARB/thiazide combos monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced) [amlodipine/ARB/thiazide combos: amlodipine/valsartan/hydrochlorothiazide, olmesartan/amlodipine/hydrochlorothiazide]

amlodipine/atorvastatin monitor BP, cholesterol levels: combo may decr. both statin and calcium channel blocker levels, efficacy (hepatic metab. induced) antacids give 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] aprepitant caution advised, monitor efficacy: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) [aprepitant: aprepitant, fosaprepitant] aripiprazole adjust aripiprazole dose, may be doubled up to max 30 mg/day: combo may decr. aripiprazole levels, efficacy (hepatic metab. induced) aspirin caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/caffeine caution 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 carbonate give 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/dextromethorphan caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/chlorpheniramine/dextromethorphan/phenylephrine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/chlorpheniramine/phenylephrine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/diphenhydramine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/dipyridamole caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/doxylamine/dextromethorphan/phenylephrine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

aspirin/phenylephrine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) atazanavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) bexarotene caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) bismuth subcitrate potassium/metronidazole/tetracycline monitor levels: combo w/ metronidazole may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) bismuth subsalicylate/metronidazole/tetracycline monitor levels: combo w/ metronidazole, salicylates may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited, protein binding displacement) bosentan caution advised, monitor phenytoin levels: combo may decr. bosentan levels, decr. phenytoin levels (hepatic metab. induced) butalbital/acetaminophen caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced, incr. toxic acetaminophen metabolite formation) calcitriol monitor efficacy; consider calcitriol dose adjustment: enzyme induction may decr. endogenous calcitriol levels, resulting in incr. supplemental calcitriol requirements (hepatic metab. induced) calcium carbonate/magnesium hydroxide give 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 salts give 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] capecitabine monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown) carbamazepine monitor levels: combo may alter levels of both drugs; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) carisoprodol/aspirin caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement)

carisoprodol/aspirin/codeine caution 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) carvedilol monitor efficacy: combo may decr. carvedilol levels, efficacy (hepatic metab. induced) caspofungin consider incr. caspofungin dose to 70 mg/day in adults, 70 mg/m^2 in peds: combo may decr. caspofungin levels, efficacy (hepatic metab. induced) chloramphenicol monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) cimetidine monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) cinacalcet monitor iPTH, serum calcium: combo may decr. cinacalcet levels, efficacy (hepatic metab. induced) ciprofloxacin monitor levels: combo may incr. or decr. phenytoin levels (hepatic metab. altered) clarithromycin monitor phenytoin levels: combo may decr. clarithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown) clopidogrel caution advised, monitor phenytoin levels: may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) clozapine caution 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 combos caution 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] colesevelam give phenytoin >4h before; monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (absorption decreased) cyclosporine monitor levels: combo may decr. cyclosporine levels, efficacy (hepatic metab. induced) [cyclosporine: cyclosporine modified, cyclosporine non-modified] darunavir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

diazepam caution 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] digoxin monitor digoxin levels: combo may decr. digoxin levels, efficacy (P-glycoprotein induced) disopyramide monitor levels: combo may decr. disopyramide levels, efficacy (hepatic metab. induced) disulfiram monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) doxorubicins monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown) [doxorubicins: doxorubicin, doxorubicin liposomal] efavirenz caution advised, monitor phenytoin levels: combo may decr. efavirenz levels, efficacy; alter phenytoin levels (hepatic metab. altered) efavirenz/emtricitabine/tenofovir disoproxil caution advised, monitor phenytoin levels: combo w/ efavirenz may alter phenytoin levels; decr. efavirenz levels, efficacy (hepatic metab. altered) erythromycins monitor 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] ethosuximide monitor ethosuximide levels: combo may decr. ethosuximide levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; mechanism unknown) exemestane adjust exemestane dose to 50 mg/day: combo may decr. exemestane levels, efficacy (hepatic metab. induced) exenatide monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) ezogabine consider 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 hydroxide give phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased)

felbamate monitor phenytoin levels, consider phenytoin dose reduction: combo may incr. phenytoin levels, risk of toxicity; decr. felbamate levels, efficacy (hepatic metab. altered) fenofibrate monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) [fenofibrate: fenofibrate, fenofibrate micronized, fenofibric acid] fluconazole monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fluorouracil monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fluoxetine monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fluvastatin monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fluvoxamine monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fosamprenavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) gefitinib consider incr. gefitinib dose to 500 mg/day: combo may decr. gefitinib levels, efficacy (hepatic metab. induced) gemfibrozil monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) growth hormone monitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) [growth hormone: somatropin (recombinant)] guanfacine consider incr. guanfacine dose: combo may decr. guanfacine levels, efficacy (hepatic metab. induced) imatinib incr. imatinib dose 50%, monitor response: combo may decr. imatinib levels, efficacy (hepatic metab. induced) indinavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) influenza vaccine caution 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] insulins monitor 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] isoniazid monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) itraconazole caution advised, monitor efficacy: combo may decr. antifungal levels, efficacy (hepatic metab. induced) ketoconazole caution advised, monitor phenytoin levels: combo may decr. antifungal levels, efficacy; incr. phenytoin levels, risk of toxicity (hepatic metab. altered) lamotrigine caution 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/clarithromycin monitor phenytoin levels: combo may decr. clarithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown) leflunomide monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) leucovorin caution advised, monitor levels: combo may decr. anticonvulsant levels, efficacy (mechanism unknown) levoleucovorin caution advised, monitor levels: combo may decr. anticonvulsant levels, efficacy (mechanism unknown) liraglutide monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) lithium monitor levels: combo may incr. lithium levels, risk of toxicity (mechanism unknown) magnesium hydroxide/mineral oil give oral phenytoin 2h before or 4h after: combo w/ antacids may decr. phenytoin levels, efficacy (absorption decreased) magnesium salts give 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]

maraviroc adjust 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) mefloquine monitor levels, efficacy: combo may decr. levels, efficacy of both drugs (mechanism unknown, hepatic metab. possibly altered) metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) metformin/sulfonylurea combos monitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects) [metformin/sulfonylurea combos: glipizide/metformin, glyburide/metformin] methadone monitor for efficacy, withdrawal: combo may decr. methadone levels, efficacy; precipitate opioid withdrawal symptoms (hepatic metab. induced) methylphenidate monitor 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] metronidazole monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) miglitol monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) modafinil monitor 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] nateglinide monitor glucose: combo may decr. nateglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) nelfinavir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) nitazoxanide monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) olanzapine/fluoxetine monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) omeprazole monitor 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/amoxicillin monitor 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) oxcarbazepine monitor 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/aspirin caution 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) paroxetine monitor phenytoin levels, monitor paroxetine efficacy: combo may incr. phenytoin levels, risk of toxicity; may decr. paroxetine levels, efficacy (hepatic metab. altered) phenobarbital monitor levels: combo may decr. levels of both drugs (hepatic metab. induced) phenobarbital/hyoscyamine/atropine/scopolamine monitor levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) pioglitazone monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) pioglitazone/glimepiride monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) pioglitazone/metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) primidone monitor levels: combo may incr. phenobarbital levels, decr. phenytoin levels (hepatic metab. induced; incr. conversion of primidone to phenobarbital) propoxyphene/acetaminophen caution 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] quinidine monitor levels: combo may decr. quinidine levels, efficacy (hepatic metab. induced) [quinidine: quinidine gluconate, quinidine sulfate]

repaglinide monitor glucose: combo may decr. repaglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) repaglinide/metformin monitor glucose: combo may decr. repaglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) rifampins monitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) [rifampins: rifampin, rifampin/isoniazid, rifampin/isoniazid/pyrazinamide] rifapentine monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) ritonavir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) rosiglitazone monitor glucose: combo may decr. rosiglitazone levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) rosiglitazone/glimepiride monitor glucose: combo may decr. rosiglitazone levels; may decr. hypoglycemic agent efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) rosiglitazone/metformin monitor glucose: combo may decr. rosiglitazone levels; may decr. hypoglycemic agent efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) rufinamide monitor 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-acetylated caution 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] saquinavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) saxagliptin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) saxagliptin/metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

sertraline monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown, hepatic metab. possibly inhibited) sevelamer give anticonvulsant 1h before or 3h after, monitor efficacy: combo may decr. anticonvulsant levels, efficacy (absorption possibly decreased) sitagliptin monitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects) sitagliptin/metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) sitagliptin/simvastatin monitor 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 substrates monitor efficacy: combo may decr. statin levels, efficacy (hepatic metab. induced) [statins, CYP3A4 substrates: atorvastatin, ezetimibe/simvastatin, lovastatin, simvastatin] sucralfate give oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased) sulfonylureas monitor 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] tacrolimus monitor levels: combo may decr. tacrolimus levels, efficacy (hepatic metab. induced) telithromycin monitor phenytoin levels: combo may decr. telithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown) tesamorelin monitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) theophyllines monitor levels: combo may decr. theophylline levels, efficacy (hepatic metab. induced) [theophyllines: aminophylline, theophylline] thyroid hormones monitor 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)] tiagabine caution 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)

ticlopidine monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) tinidazole monitor levels, efficacy: combo may incr. phenytoin levels, risk of toxicity; decr. tinidazole levels, efficacy (hepatic metab. inhibited; hepatic metab. induced) tipranavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) TNF blocking agents monitor 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] tocilizumab monitor 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) topiramate monitor levels: combo may incr. phenytoin levels, risk of toxicity; decr. topiramate levels, efficacy (hepatic metab. altered) [topiramate: phentermine hydrochloride/topiramate, topiramate] trazodone caution advised, monitor phenytoin levels: combo may decr. trazodone levels, efficacy; may incr. phenytoin levels, risk of toxicity (hepatic metab. induced; mechanism unknown) trimethoprim monitor levels, CBC: combo may incr. phenytoin levels, risk of toxicity, risk of megaloblastic anemia (hepatic metab. inhibited, additive/synergistic folate antagonism) trimethoprim/sulfamethoxazole monitor levels, CBC: combo w/ trimethoprim may incr. phenytoin levels, risk of toxicity, risk of megaloblastic anemia (hepatic metab. inhibited, additive/synergistic folate antagonism) ustekinumab monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. possibly altered; ustekinumab may normalize hepatic enzyme formation suppressed by incr. cytokine levels) valacyclovir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown) valproic acid derivatives monitor 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]

vigabatrin monitor phenytoin levels: combo may decr. phenytoin levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) voriconazole incr. 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) warfarin monitor INR: combo may decr. INR, warfarin efficacy and transiently incr. INR, risk of bleeding (hepatic metab. induced, protein binding displacement) zafirlukast monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

Caution Advised

abiraterone acetate caution advised: combo may decr. abiraterone levels, efficacy (hepatic metab. induced) aldesleukin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) alendronate/cholecalciferol caution advised: combo may decr. cholecalciferol efficacy (hepatic metab. induced) alfentanil caution advised: combo may decr. alfentanil efficacy (hepatic metab. induced) apomorphine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive/synergistic effects) artemether/lumefantrine caution advised: combo may decr. artemether/lumefantrine levels, efficacy (hepatic metab. induced) azelastine nasal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal] belatacept caution advised: combo may decr. phenytoin levels, efficacy (hepatic metab. possibly altered; belatacept may normalize hepatic enzyme formation suppressed by incr. cytokine levels) benzocaine contraindicated 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 combos contraindicated 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 substrates caution 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, other caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [benzodiazepines, other: clobazam, estazolam, lorazepam, oxazepam, temazepam] black cohosh caution 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] bromocriptine caution advised: combo may decr. bromocriptine levels, efficacy (hepatic metab. induced) budesonide caution advised: combo may decr. budesonide levels, efficacy (hepatic metab. induced) buprenorphine caution advised: combo may decr. buprenorphine levels, efficacy (hepatic metab. induced) [buprenorphine: buprenorphine, buprenorphine transdermal, buprenorphine/naloxone] bupropion caution advised: combo may decr. buproprion efficacy (hepatic metab. induced) [bupropion: bupropion hydrobromide, bupropion hydrochloride] buspirone caution advised: combo may decr. buspirone levels, efficacy (hepatic metab. induced) busulfan caution advised: combo may decr. busulfan levels, efficacy (hepatic metab. induced) caffeine caution advised: combo may decr. caffeine levels, efficacy (hepatic metab. induced) [caffeine: caffeine, caffeine citrate, caffeine/sodium benzoate] carbidopa/levodopa caution advised: combo may decr. levodopa efficacy (mechanism unknown) carbidopa/levodopa/entacapone caution advised: combo may decr. levodopa efficacy (mechanism unknown) carbonic anhydrase inhibitors, systemic caution advised: combo may incr. risk of osteomalacia (calcium renal excretion increased,

metabolic acidosis) [carbonic anhydrase inhibitors, systemic: acetazolamide, methazolamide] chlordiazepoxide caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) clonazepam caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) clorazepate caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) colchicine caution advised: combo may decr. colchicine levels, efficacy (hepatic metab. induced) conivaptan caution advised: combo may decr. conivaptan levels, efficacy (hepatic metab. induced) corticosteroids, systemic caution 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] cyclophosphamide caution advised: combo may incr. cyclophosphamide active metabolite levels, risk of toxicity (hepatic metab. induced, incr. active metabolite formation) dantrolene caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) dapsone caution advised: combo may decr. dapsone levels, efficacy (hepatic metab. induced) darifenacin caution advised: combo may decr. darifenacin levels, efficacy (hepatic metab. induced) dasatinib caution advised: combo may decr. dasatinib levels, efficacy (hepatic metab. induced) diazoxide caution advised: combo may incr. risk of hyperglycemia; combo w/ PO diazoxide may decr. phenytoin levels, incr. risk of seizures (additive effects; mechanism unknown) diclofenac caution advised: combo may decr. diclofenac levels, efficacy (hepatic metab. induced) [diclofenac: diclofenac potassium, diclofenac sodium, diclofenac/misoprostol] docetaxel caution advised: combo may decr. docetaxel levels, efficacy (hepatic metab. induced) donepezil caution advised: combo may decr. donepezil levels, efficacy (hepatic metab. induced) doxercalciferol caution advised: combo may decr. doxercalciferol efficacy (hepatic metab. induced)

doxycycline caution advised, monitor efficacy: combo may decr. doxycycline levels, efficacy (mechanism unknown) eplerenone caution advised: combo may decr. eplerenone levels, efficacy (hepatic metab. induced) ergotamine/caffeine caution advised: combo may decr. caffeine levels, efficacy (hepatic metab. induced) eszopiclone caution advised: combo may decr. eszopiclone levels, efficacy (hepatic metab. induced) ethanol caution 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) fentanyl caution advised: combo may decr. fentanyl levels, efficacy (hepatic metab. induced) [fentanyl: fentanyl, fentanyl nasal, fentanyl transdermal, fentanyl transmucosal] flurazepam caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) gabapentin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [gabapentin: gabapentin, gabapentin enacarbil] green tea caution 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] haloperidol caution advised: combo may decr. haloperidol levels, efficacy (mechanism unknown) [haloperidol: haloperidol, haloperidol decanoate, haloperidol lactate] HRT, estrogen caution 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 combo caution 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, progestin caution advised: combo may decr. progestin levels, efficacy (hepatic metab. induced) [HRT, progestin: medroxyprogesterone, norethindrone acetate] hydromorphone caution 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] ifosfamide caution 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) isotretinoin caution advised: combo may incr. risk of bone loss (additive effects) kava caution 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] ketamine caution advised: combo may decr. ketamine levels, efficacy (hepatic metab. induced) levocetirizine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) levonorgestrel intrauterine device caution advised: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) lidocaine topical contraindicated 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] linezolid caution advised: combo may decr. linezolid levels, efficacy (mechanism unknown, hepatic metab. possibly induced) meperidine caution advised: combo may decr. meperidine levels, analgesic efficacy, may incr. risk of normeperidine neurotoxicity (hepatic metab. induced, incr. toxic metabolite formation) meprobamate caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) mirtazapine caution advised: combo may decr. mirtazepine levels, effects (hepatic metab. induced)

mitotane caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) montelukast caution advised: combo may decr. montelukast levels, efficacy (hepatic metab. induced) morphine liposomal caution advised: combo may incr. risk of CNS depression, profound sedation, hypotension, other adverse effects (additive effects) nafarelin nasal caution advised: combo may incr. risk of bone loss (additive effects) nevirapine caution advised: combo may decr. nevirapine levels, efficacy (hepatic metab. induced) niacin/lovastatin caution advised: combo may decr. lovastatin levels, efficacy (hepatic metab. induced) niacin/simvastatin caution advised: combo may decr. simvastatin levels, efficacy (hepatic metab. induced) nitrites/sodium thiosulfate caution advised: combo w/ nitrites may incr. risk of methemoglobinemia (additive effects) [nitrites/sodium thiosulfate: amyl nitrite/sodium nitrite/sodium thiosulfate, sodium nitrite/sodium thiosulfate] nitroprusside caution advised: combo may incr. risk of methemoglobinemia (additive effects) olopatadine nasal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) oxycodone caution advised, consider dose adjustment: combo may decr. oxycodone levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) oxycodone/ibuprofen caution advised, consider dose adjustment: combo may decr. oxycodone levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) paclitaxel caution advised: combo may decr. paclitaxel levels, efficacy (hepatic metab. induced) [paclitaxel: paclitaxel, paclitaxel nanoparticle albumin-bound] peginterferon alfa 2b caution advised: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) pimozide caution 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) pramipexole caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

pregabalin caution 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] propofol caution advised: combo may incr. risk of CNS depression, psychomotor impairment; may decr. propofol levels, efficacy (additive effects; hepatic metab. induced) [propofol: fospropofol, propofol] propoxyphene caution advised: combo may decr. propoxyphene levels, efficacy, incr. active metabolite formation, risk of toxicity (hepatic metab. induced) [propoxyphene: propoxyphene hydrochloride, propoxyphene napsylate] quetiapine caution advised: combo may decr. quetiapine levels, efficacy (clearance increased) quinine sulfate caution advised: combo may decr. quinine levels, efficacy (hepatic metab. induced) ramelteon caution advised: combo may decr. ramelteon levels, efficacy (hepatic metab. induced) risperidone caution advised: combo may decr. risperidone levels, efficacy (hepatic metab. induced) romidepsin caution advised: combo may decr. romidepsin levels, efficacy (hepatic metab. induced) ropinirole caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) rotigotine transdermal caution advised: combo may incr. phenytoin levels, risk of toxicity; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. inhibited; additive effects) ruxolitinib caution advised: combo may decr. ruxolitinib levels, efficacy, may incr. active metabolite formation, risk of adverse effects (hepatic metab. induced) selegiline caution advised: combo may decr. selegiline levels, efficacy (hepatic metab. induced) selegiline transdermal caution advised: combo may decr. selegiline levels, efficacy (hepatic metab. induced) sildenafil caution advised: combo may decr. sildenafil levels, efficacy (hepatic metab. induced) sodium oxybate caution advised: combo may incr. risk of CNS depression, other adverse effects (additive effects)

solifenacin caution advised: combo may decr. solifenacin levels, efficacy (hepatic metab. induced) sorafenib caution advised, monitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects; decr. sorafenib levels, efficacy (hepatic metab. inhibited; hepatic metab. induced) streptozocin caution advised: combo may decr. streptozocin efficacy (mechanism unknown) sufentanil caution advised: combo may decr. sufentanil efficacy (hepatic metab. induced) tamoxifen caution advised: combo may decr. tamoxifen and active metabolite levels, efficacy (hepatic metab. induced) tapentadol caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) teniposide caution advised: combo may decr. teniposide levels, efficacy (hepatic metab. induced) tetrabenazine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) thiotepa caution advised: combo may decr. thiotepa levels, efficacy; may incr. thiotepa active metabolite levels, risk of toxicity (hepatic metab. induced) toremifene caution advised: combo may decr. toremifene levels, efficacy (hepatic metab. induced) tricyclic antidepressants caution 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] vemurafenib caution advised: combo may decr. vemurafenib levels, efficacy (hepatic metab. induced) vinca alkaloids caution advised: combo may decr. vinca alkaloid levels, efficacy (hepatic metab. induced) [vinca alkaloids: vinblastine, vincristine, vinorelbine] zaleplon caution advised: combo may decr. zaleplon levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) zolpidem caution advised: combo may decr. zolpidem levels, efficacy (hepatic metab. induced) zonisamide caution 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: 710 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 Action modulates 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 Genrico: phenytoin (oral) Nombres de las Marcas: Dilantin, Dilantin Infatabs, Dilantin-125, Phenytek

Cul es la informacin ms importante que debo saber sobre phenytoin?

Usted no debe tomar phenytoin si usted tambin est tomando delavirdine (Rescriptor), o si es alrgico a phenytoin, ethotoin (Peganone), fosphenytoin (Cerebyx), o mephenytoin (Mesantoin).

Si usted est embarazada, NO EMPIECE A TOMAR phenytoin salvo que su mdico le haya indicado hacerlo. Phenytoin puede hacer dao al beb nonato, pero tener una convulsin cuando est embarazada le puede hacer dao a la madre y al beb. Si usted queda embarazada mientras est tomando phenytoin, NO DEJE DE TOMAR la medicina sin el consejo de su mdico. 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 mdico necesitar examinarlo con regularidad. No falte a las visitas mdica establecidas por su mdico.

Informe a su mdico de algn sntoma nuevo o que empeora, como: cambios del humor o del comportamiento, depresin, ansiedad, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o de fsico), o tiene pensamientos de suicidio o de querer hacerse dao.

Qu es phenytoin?
Phenytoin es una droga antiepilptica, tambin 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 mdico determinar si es la medicina correcta para usted. Phenytoin puede tambin usarse para fines no mencionados en esta gua del medicamento.

Qu debera discutir con el profesional del cuidado de la salud antes de usar phenytoin?
Usted no debe tomar phenytoin si usted tambin est tomando delavirdine (Rescriptor), o si es alrgico a phenytoin, ethotoin (Peganone), fosphenytoin (Cerebyx), o mephenytoin (Mesantoin). Para asegurarse que usted puede tomar phenytoin de forma segura, dgale a su mdico si usted tiene cualquiera de estas otras condiciones:

enfermedad del hgado; lupus; diabetes; deficiencia de la vitamina D o cualquier otra condicin que desgasta los huesos; porfiria (un trastorno gentico de enzima que causa sntomas 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. Dgale a su mdico si usted tiene sntomas de la depresin 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 tambin deben mantenerse alertas a los cambios en su humor o sntomas. Su mdico necesitar examinarlo con regularidad. No falte a las visitas mdicas establecidas por su mdico. Los pacientes con antepasados de origen Asitico pueden tener un riesgo ms alto de desarrollar una reaccin a la piel, rara, pero de gravedad con phenytoin. Su mdico puede recomendar pruebas de la sangre antes de que empiece la medicina para determinar su riesgo a tener esta reaccin.

Categora D del embarazo por la FDA. Phenytoin le puede hacer dao al beb nonato, pero tener una convulsin cuando est embarazada le puede hacer dao a la madre y al beb.

Si usted est embarazada, NO EMPIECE A TOMAR phenytoin salvo que su mdico le haya indicado. Si usted queda embarazada mientras est tomando phenytoin, NO DEJE DE TOMAR la medicina sin el consejo de su mdico. 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 mdico acerca de tomar phenytoin durante su embarazo. Phenytoin puede hacer las pastillas anticonceptivas menos efectivas. Para prevenir el embarazo mientras toma phenytoin, use un mtodo de control de natalidad no hormonal (como el condn o diafragma con espermicida).

Phenytoin puede pasar a la leche materna y causarle dao al beb lactante. Usted no debe amamantar mientras est usando phenytoin.

Cmo debo tomar phenytoin?

Tmelo exactamente cmo lo haya recetado su mdico. No lo tome en cantidades mayores o menores, o por ms tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripcin.

No triture, mastique, rompa, o abra una cpsula de liberacin extendida. Trguelas enteras. Romper o abrir la pldora puede causar que mucha medicina pase al cuerpo de inmediato. No use ninguna cpsula que ha cambiado de color. Llame a su mdico para una nueva prescripcin.

Agite bien la suspensin oral (lquida) antes de medir una dosis. Mida el lquido con una cucharita o taza de medicin, no lo haga con una cuchara normal. Si no tiene con que medir su dosis, pdale una a su farmacutico. Para estar seguro de que este medicamento est ayudando su condicin, tal vez se necesite examinar su sangre con frecuencia. Tambin puede ser que necesite exmenes de sangre cuando cambie de una presentacin de phenytoin a otra. Visite a su mdico con regularidad.

Si est 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 aprobacin de su mdico. Dgale a su mdico si le parece que su medicina ha dejado de funcionar como lo hacia para el tratamiento de su condicin.

Lleve con usted una tarjeta de identificacin que indique que usted est tomando phenytoin. Cualquier proveedor del cuidado mdico que lo trate debera saber que usted esta usando una medicina para el control de convulsiones.

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

Qu sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome ms medicina para alcanzar la dosis pasada.

Qu sucedera en una sobredosis?

Busque atencin mdica de emergencia o llame a la lnea de Poison Help al 1-800-222-1222. La sobredosis de phenytoin puede ser fatal. Los sntomas de sobredosis pueden incluir movimientos espasmdicos de los ojos, arrastre de las palabras al hablar, perdida del balance, temblores, rigidez muscular o debilidad, nusea, vmito, sentir que se puede desmayar, desmayo, y respiracin lenta o no profunda.

Qu debo evitar mientras uso phenytoin?

Evite beber alcohol mientras est 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 anticidos al mismo tiempo que toma phenytoin. Los anticidos pueden hacer ms difcil para que su cuerpo pueda absorber la medicina.

Phenytoin puede perjudicar su pensamiento o reacciones. Tenga cuidado si usted conduce un vehculo o tenga que hacer algo que demande se mantenga alerta.

Cules son los efectos secundarios posibles de phenytoin?

Busque atencin mdica de emergencia si usted tiene alguno de estos sntomas de una reaccin alrgica: ronchas; dificultad para respirar; hinchazn de su cara, labios, lengua, o garganta. Es ms probable que tenga una reaccin alrgica si es de raza Americana-Africana.

Informe a su mdico de algn sntoma nuevo o que empeora, como: cambios del humor o del comportamiento, depresin, ansiedad, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o de fsico), o tiene pensamientos de suicidio o de querer hacerse dao.

Llame a su mdico de inmediato si usted tiene un efecto secundario grave como:

fiebre, glndulas hinchadas, dolor de cuerpo, sntomas de la gripe; sarpullido, moretones o sangrado fcil, hormigueo severo, entumecimiento, dolor, debilidad muscular; dolor en la parte superior del estmago, prdida del apetito, orina oscura, ictericia (color amarillo de la piel u ojos); dolor de pecho, ritmo cardaco irregular, sensacin de que le falta aire al respirar; confusin, nusea y vmito, hinchazn, ganancia de peso rpida, 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 reaccin severa de la piel -- fiebre, dolor de garganta, hinchazn en su cara o lengua, quemazn en sus ojos, dolor de la piel, seguido por un sarpullido rojo o prpura que se extiende (especialmente en la cara o la parte superior del cuerpo) y causa ampollas y descamacin.

Efectos secundarios de menor gravedad pueden incluir:

habla arrastrado, perdida del balance o coordinacin; encas 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 mdico para consejos mdicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

Qu otras drogas afectarn a phenytoin?

Varias drogas pueden tener interacciones con phenytoin. La lista que se presenta abajo no incluye todas las drogas. Dgale a su mdico si usted est usando:

antibiticos 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 corazn 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 cido del estmago (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. Dgale a su mdico 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 mdico. Mantenga una lista de todas sus medicinas y mustresela a cualquier profesional de la salud que lo atienda.

Dnde puedo obtener ms informacin?

Su farmacutico le puede dar ms informacin acerca de phenytoin.

Drug

Gralise
gabapentin

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 biloba avoid 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

antacids give 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 carbonate give gabapentin 2h after oral calcium: combo may decr. gabapentin efficacy (absorption decreased via chelation) calcium carbonate/magnesium hydroxide give 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 salts give 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 hydroxide give gabapentin 2h after: combo may decr. gabapentin efficacy (absorption decreased via chelation) iron salts, oral give gabapentin 2h after iron: combo may decr. gabapentin efficacy (absorption decreased via chelation) [iron salts, oral: ferrous gluconate, ferrous sulfate] magnesium hydroxide/mineral oil give gabapentin 2h after antacid: combo may decr. gabapentin efficacy (absorption decreased) magnesium salts give gabapentin 2h after oral magnesium: combo may decr. gabapentin efficacy (absorption

decreased via chelation) [magnesium salts: magnesium citrate, magnesium gluconate, magnesium oxide, magnesium sulfate] methadone caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) sevelamer give anticonvulsant 1h before or 3h after, monitor efficacy: combo may decr. anticonvulsant levels, efficacy (absorption possibly decreased)

Caution Advised

acetaminophen/caffeine/CNS depressant combos caution 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/chlorpheniramine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) acetaminophen/chlorpheniramine/dextromethorphan caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) acetaminophen/chlorpheniramine/dextromethorphan/phenylephrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) acetaminophen/chlorpheniramine/phenylephrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) acetaminophen/codeine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) acetaminophen/diphenhydramine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) acetaminophen/diphenhydramine/dextromethorphan caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) acetaminophen/diphenhydramine/phenylephrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) acetaminophen/doxylamine/dextromethorphan caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

acetaminophen/doxylamine/dextromethorphan/phenylephrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) acetaminophen/doxylamine/dextromethorphan/pseudoephedrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) acetaminophen/doxylamine/phenylephrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) acetaminophen/pheniramine/phenylephrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) aldesleukin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) alfentanil caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) antidepressants, other caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [antidepressants, other: maprotiline, mirtazapine, nefazodone, trazodone] antihistamine/decongestant combos caution 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, sedating caution 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] antipsychotics caution 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] apomorphine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) aspirin/chlorpheniramine/dextromethorphan caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects)

aspirin/chlorpheniramine/dextromethorphan/phenylephrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) aspirin/chlorpheniramine/phenylephrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) aspirin/diphenhydramine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) aspirin/doxylamine/dextromethorphan/phenylephrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) azelastine nasal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal] barbiturates caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [barbiturates: butabarbital, methohexital, pentobarbital, phenobarbital, primidone, secobarbital, thiopental] benzodiazepines, all caution 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/phenylephrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) brompheniramine/dextromethorphan/pseudoephedrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) butalbital/acetaminophen caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) calendula caution 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] cannabinoids caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [cannabinoids: dronabinol, nabilone] capsicum caution 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] carbamazepine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) carisoprodol/aspirin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) central alpha 2 agonists caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [central alpha 2 agonists: clonidine, clonidine transdermal, guanabenz, guanfacine, methyldopa] cetirizine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) cetirizine/pseudoephedrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) chamomile, German caution 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/dextromethorphan caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) chlorpheniramine/dextromethorphan/pseudoephedrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) CNS depressant/aspirin/caffeine combos caution 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] codeine caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [codeine: codeine phosphate, codeine sulfate] codeine/guaifenesin caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) dantrolene caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

dexmedetomidine caution advised, consider dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) doxylamine/dextromethorphan caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) droperidol caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) ethanol caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects; alcohol withdrawal or excessive use may lower seizure threshold) ethosuximide caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) etomidate caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) ezogabine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) fentanyl caution 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, Siberian caution 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] goldenseal caution 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 kola caution 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] hawthorn caution 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]

hydrocodones caution 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] hydromorphone caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) inhaled anesthetics caution advised, consider dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [inhaled anesthetics: desflurane, enflurane, isoflurane, sevoflurane] kava caution 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] ketamine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) lemon balm caution 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] levocetirizine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) levorphanol caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) meperidine caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) meprobamate caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) metoclopramide caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) mitotane caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) morphine caution 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 liposomal caution advised: combo may incr. gabapentin levels, risk of somnolence, other adverse effects; incr. analgesic effects of morphine (absorption increased, clearance decreased; additive effects) muscle relaxants caution 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 caution advised: combo may incr. gabapentin levels, risk of somnolence, other adverse effects (mechanism unknown) [naproxen: naproxen, naproxen sodium] naproxen/esomeprazole caution advised: combo w/ naproxen may incr. gabapentin levels, risk of somnolence, other adverse effects (mechanism unknown) NSAID/chlorpheniramine/pseudoephedrine combos caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) [NSAID/chlorpheniramine/pseudoephedrine combos: ibuprofen/chlorpheniramine/pseudoephedrine] NSAID/diphenhydramine combos caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) [NSAID/diphenhydramine combos: ibuprofen/diphenhydramine] olanzapine/fluoxetine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) olopatadine nasal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) opiate agonist/antagonists caution 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 combos caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [opiate/aspirin combos: carisoprodol/aspirin/codeine, oxycodone/aspirin] oxcarbazepine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

oxycodone caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) oxycodone/acetaminophen caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) oxycodone/ibuprofen caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) oxymorphone caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) passionflower caution 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/acetaminophen caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) pheniramine/dextromethorphan/phenylephrine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) phenobarbital/hyoscyamine/atropine/scopolamine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) phenothiazines caution 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] phenytoins caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [phenytoins: fosphenytoin, phenytoin] pimozide caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) pramipexole caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) pregabalin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

promethazine/codeine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) propofol caution advised, consider dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [propofol: fospropofol, propofol] remifentanil caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) ropinirole caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) rotigotine transdermal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) rufinamide caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) sedative/hypnotics caution 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 oxybate caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) sufentanil caution advised, consider opioid dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) sumatriptan/naproxen sodium caution advised: combo w/ NSAIDs may incr. gabapentin levels, risk of somnolence, other adverse effects (mechanism unknown) tapentadol caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) tetrabenazine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) thalidomide caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) tiagabine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) topiramate caution advised: combo may incr. risk of CNS depression, psychomotor impairment

(additive effects) [topiramate: phentermine hydrochloride/topiramate, topiramate] tramadol caution advised, especially in non-epileptic pts: combo may incr. risk of CNS depression, psychomotor impairment, seizures (additive effects; seizure threshold lowered by tramadol) tramadol/acetaminophen caution advised, especially in non-epileptic pts: combo may incr. risk of CNS depression, psychomotor impairment, seizures (additive effects; seizure threshold lowered by tramadol) tricyclic antidepressants caution 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] valerian caution 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 derivatives caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid] vigabatrin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) ziconotide intrathecal caution advised: combo may incr. risk of confusion, dizziness, other CNS adverse effects (additive effects) [ziconotide intrathecal: ziconotide] zonisamide caution 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 drugspecific 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 Action exact 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 Genrico: gabapentin Nombres de las Marcas: Gralise, Horizant, Neurontin

Cul es la informacin ms importante que debo saber sobre gabapentin?

Usted no debe usar esta medicina si es alrgico a gabapentin.

Antes de tomar gabapentin, dgale a su mdico si usted tiene enfermedad de los riones, del hgado, o enfermedad del corazn. Usted puede tener pensamientos de suicidio mientras est tomando gabapentin. Su mdico necesitar chequearlo con regularidad. No falta a ninguna de las visitas mdicas establecidas. Informe a su mdico de algn sntoma nuevo o que empeora, como: cambios del humor o del comportamiento, ansiedad, depresin, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o fsicamente), o piensa en suicidarse o hacerse dao.

No deje de toma gabapentin para convulsiones sin antes hablar con su mdico, aunque se sienta bien. Usted puede tener un aumento en convulsiones si deja de tomar gabapentin de forma repentina. Usted necesitar reducir su dosis lentamente antes de dejar de tomar la medicina por completo. Comunquese con su mdico si sus convulsiones empeoran o las tiene con ms frecuencia mientras est tomando gabapentin.

Lleve con usted una tarjeta de identificacin que indique que usted est tomando gabapentin. Cualquier mdico, dentista, o profesional del cuidado de la salud que lo trate debera saber que usted toma medicamentos para las convulsiones.

Qu es gabapentin?
Gabapentin es una medicina antiepilptica, tambin conocida como anticonvulsante. sta afecta a los qumicos y nervios del cuerpo que estn involucrados en las causas de convulsiones y algunos tipos de dolores. Gabapentin se usa solo o en combinacin con otras medicinas para el tratamiento de las convulsiones que causan epilepsia en adultos y nios que tienen por lo menos 12 aos de edad. Gabapentin tambin se usa con otras medicinas para el tratamiento de convulsiones parciales en nios que tienen de 3 a 12 aos de edad. Gabapentin tambin 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 sndrome de la piernas inquietas (RLS, por sus siglas en Ingls). Gabapentin puede tambin usarse para fines no mencionados en esta gua del medicamento.

Qu debera discutir con el profesional del cuidado de la salud antes de usar gabapentin?

Usted no debe usar este medicamento si es alrgico a gabapentin. Para asegurarse que usted puede tomar gabapentin de forma segura, dgale a su mdico si usted tiene cualquiera de estas otras condiciones:

enfermedad del rin; enfermedad del hgado; enfermedad del corazn; o (para pacientes con sndrome de la piernas inquietas) si usted duerme durante el da o hace el turno de noche.

Usted puede tener pensamientos de suicidio mientras est tomando esta medicina. Dgale a su mdico si usted tiene depresin 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 sntomas. Su mdico necesitar chequearlo con regularidad. No falte a ninguna de las visitas establecidas por su mdico.

Categora C del embarazo por la FDA. No se conoce si gabapentin causar dao al beb nonato. Dgale a su mdico si usted est embarazada o planea quedar embarazada mientras est usando este medicamento.

Gabapentin puede pasar a la leche materna y le puede hacer dao al beb que est mamando. No use esta medicina sin antes hablar con su mdico si le est dando de amamantar al beb.

Cmo debo tomar gabapentin?

Tmelo exactamente como lo haya recetado su mdico. No lo tome en cantidades mayores o menores, o por ms tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripcin.

La marca de Horizant de gabapentin no debe ser tomada durante el da. 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 prxima dosis. Cualquier tableta que se rompa debe usarse lo ms pronto posible o dentro de pocos das. Mida la medicina lquida 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, pdale una a su farmacutico.

No deje de toma gabapentin para convulsiones sin primero hablar con su mdico, aunque se sienta bien. Usted puede tener un aumento de convulsiones si deja de usar gabapentin de forma sbita. Usted tal vez necesite reducir su dosis lentamente antes de dejar de tomar el medicamento por completo. Comunquese con su mdico si sus convulsiones empeoran o las tiene con ms frecuencia mientras est tomando gabapentin.

Lleve con usted una tarjeta de identificacin que indique que usted est tomando gabapentin. Cualquier mdico, dentista, o profesional del cuidado de la salud que lo trate debera saber que usted toma medicamentos para las convulsiones. Use gabapentin regularmente para obtener el mayor beneficio. Vuelva a llenar su prescripcin antes de que se quede completamente sin medicina.

Este medicamento puede causar resultados inusuales con ciertas pruebas mdicas. Dgale a cualquier mdico que lo atiende que usted est usando gabapentin.

Guarde las tabletas y cpsulas de gabapentin a temperatura ambiente lejos de la luz y humedad.

Guarde la medicina lquida en el refrigerador. No la congele.

Qu sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome ms medicina para alcanzar la dosis pasada.

Qu sucedera en una sobredosis?

Busque atencin mdica de emergencia o llame a la lnea de Poison Help al 1 800 222 1222. Los sntomas de sobredosis puede incluir visin borrosa, somnolencia, debilidad, arrastre de las palabras al hablar, o diarrea.

Qu debo evitar mientras tomo gabapentin?

Este medicamento puede causar visin borrosa o perjudicar su pensamiento o reacciones. Tenga cuidado al manejar o hacer otras actividades que demanden est alerta y sea capaz de ver claramente. Evite tomar un anticido dentro de 2 horas antes o despus de tomar gabapentin. Los anticidos puede hacer difcil para que su cuerpo pueda absorber gabapentin.

Cules son los efectos secundarios posibles de gabapentin?

Busque atencin mdica de emergencia si usted tiene alguno de estos sntomas de una reaccin alrgica: ronchas; fiebre, glndulas inflamadas; lceras dolorosas en o alrededor de sus ojos o boca; dificultad para respirar; hinchazn de su cara, labios, lengua, o garganta. Informe a su mdico de algn sntoma nuevo o que empeora, como: cambios del humor o del comportamiento, ansiedad, depresin, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o fsicamente), o piensa en suicidarse o hacerse dao.

Llame a su mdico de inmediato si usted tiene un efecto secundario grave como:

aumento en convulsiones; fiebre, glndulas hinchadas, dolor de cuerpo, sntomas de la gripe; sarpullido, moretones o sangrado fcil, hormigueo severo, entumecimiento, dolor, debilidad muscular; dolor en la parte superior del estmago, prdida del apetito, orina oscura, ictericia (color amarillo de la piel u ojos); dolor de pecho, ritmo cardaco irregular, sensacin de que le falta aire al respirar; confusin, nusea y vmito, hinchazn, ganancia de peso rpida, orinar menos de lo usual o nada en absoluto; tos nueva o que empeora, fiebre, dificultad para respirar; o movimiento de los ojos rpidos, hacia adelante y atrs.

Algunos de los efectos secundarios son ms probables en los nios que toman gabapentin. Comunquese con su mdico si el nio que est 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; nusea, diarrea, estreimiento; visin borrosa; dolor de cabeza; hinchazn en las mamas; boca seca; o prdida del equilibrio o la coordinacin.

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

Qu otras drogas afectarn a gabapentin?

Dgale a su mdico 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. Dgale a su mdico 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 mdico.

Dnde puedo obtener ms informacin?

Su farmacutico le puede dar ms informacin acerca de gabapentin.

Drug

Phenytek

phenytoin

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

boceprevir contraindicated: combo may decr. boceprevir levels, efficacy (hepatic metab. induced) delavirdine contraindicated: combo may decr. delavirdine levels, efficacy (hepatic metab. induced) emtricitabine/rilpivirine/tenofovir disoproxil contraindicated: combo may decr. rilpivirine levels, efficacy (hepatic metab. induced) etravirine contraindicated: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) lopinavir/ritonavir contraindicated 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) lurasidone contraindicated: combo may decr. lurasidone levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) praziquantel contraindicated; 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) ranolazine contraindicated: combo may decr. ranolazine levels, efficacy (hepatic metab. induced) rilpivirine contraindicated: combo may decr. rilpivirine levels, efficacy (hepatic metab. induced)

Avoid/Use Alternative

acetaminophen/codeine use 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) axitinib avoid combo: combo may decr. axitinib levels, efficacy (hepatic metab. induced) bortezomib avoid combo: combo may decr. bortezomib levels, efficacy (hepatic metab. induced) bosutinib avoid combo: combo may decr. bosutinib levels, efficacy (hepatic metab. induced) cabazitaxel avoid combo: combo may decr. cabazitaxel levels, efficacy (hepatic metab. induced) calcium channel blockers, dihydropyridines use 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, others use alternative or monitor for efficacy: combo may decr. calcium channel blocker levels,

efficacy (hepatic metab. induced) [calcium channel blockers, others: diltiazem, trandolapril/verapamil, verapamil] cobicistat avoid combo: combo may decr. cobicistat levels, efficacy (hepatic metab. induced) [cobicistat: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil] contraceptives, oral combo caution 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 progestin use additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) [contraceptives, oral progestin: norethindrone] contraceptives, other combo caution 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] crizotinib avoid combo or use alternative: combo may decr. crizotinib levels, efficacy (hepatic metab. induced) deferasirox avoid 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) dopamine use alternative or monitor BP: combo w/ IV phenytoins may incr. risk of severe hypotension (mechanism unknown, possible additive effects) dronedarone avoid combo: combo may decr. dronedarone levels, efficacy (hepatic metab. induced) elvitegravir avoid combo or use alternative: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) [elvitegravir: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil] enzalutamide avoid combo: combo may decr. levels of both drugs, efficacy (hepatic metab. induced) erlotinib use alternative or consider incr. erlotinib dose >150 mg/day: combo may decr. erlotinib levels (hepatic metab. induced)

etonogestrel subdermal implant use additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) everolimus avoid 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 biloba avoid 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/acetaminophen use 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) irinotecan avoid 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) ivacaftor avoid combo: combo may decr. ivacaftor levels, efficacy (hepatic metab. induced) ixabepilone use alternative: combo may decr. ixabepilone levels, efficacy (hepatic metab. induced) lapatinib avoid 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) levonorgestrel use alternative non-hormonal contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) linagliptin use alternative: combo may decr. linagliptin levels, efficacy (hepatic metab. induced, pglycoprotein induced, antagonistic effects) linagliptin/metformin use alternative: combo may decr. linagliptin levels, efficacy (hepatic metab. induced, Pglycoprotein induced) local anesthetics avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) [local anesthetics: bupivacaine, bupivacaine liposomal, chloroprocaine, lidocaine, mepivacaine, procaine, ropivacaine] local anesthetics/epinephrine avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive

effects) [local anesthetics/epinephrine: articaine/epinephrine] medroxyprogesterone acetate use additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) methotrexate use alternative or monitor efficacy, toxicity, levels: combo may incr. methotrexate toxicity and decr. efficacy; may decr. phenytoin levels, efficacy (mechanism unknown; absorption decreased) mifepristone avoid combo if daily mifepristone use; caution advised if pregnancy termination use: combo may decr. mifepristone levels, efficacy (hepatic metab. induced) milk thistle avoid 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] nilotinib avoid 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/acetaminophen use 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) pazopanib contraindicated if chronic use of strong CYP3A4 inducer, otherwise avoid combo or use alternative: combo may decr. pazopanib levels, efficacy (hepatic metab. induced) pentazocine/acetaminophen use 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) posaconazole weigh risk/benefit, monitor phenytoin levels: combo may decr. posaconazole levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. altered) rivaroxaban avoid combo: combo may decr. rivaroxaban levels, efficacy (hepatic metab. induced, Pglycoprotein induced) roflumilast avoid combo: combo may decr. roflumilast levels, efficacy (hepatic metab. induced) sunitinib use 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) tadalafil avoid combo in pulmonary HTN pts; caution advised for ED pts: combo may decr. tadalafil levels, efficacy (hepatic metab. induced) telaprevir avoid 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) temsirolimus avoid combo or consider incr. temsirolimus dose to 50 mg/wk: combo may decr. temsirolimus and sirolimus levels, efficacy (hepatic metab. induced) ticagrelor avoid combo: combo may decr. ticagrelor levels, efficacy (hepatic metab. induced) tolvaptan avoid combo or consider incr. tolvaptan dose: combo may decr. tolvaptan levels, efficacy (hepatic metab. induced) tramadol avoid 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/acetaminophen use 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) ulipristal use alternative non-hormonal contraception: combo may decr. ulipristal levels, contraceptive efficacy (hepatic metab. induced) vandetanib avoid combo: combo may decr. vandetanib levels, efficacy (hepatic metab. induced)

Monitor/Modify Tx

acarbose monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) acetaminophen/aspirin caution 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/caffeine caution 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/caffeine caution 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 combos caution 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/chlorpheniramine caution 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 caution 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/phenylephrine caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation) acetaminophen/chlorpheniramine/phenylephrine caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation) acetaminophen/dextromethorphan caution 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 caution 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/pseudoephedrine caution 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/diphenhydramine caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation) acetaminophen/diphenhydramine/dextromethorphan caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

acetaminophen/diphenhydramine/phenylephrine caution 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 caution 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/phenylephrine caution 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/pseudoephedrine caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation) acetaminophen/doxylamine/phenylephrine caution 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/pamabrom caution 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/pamabrom caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced, incr. toxic metabolite formation) acetaminophen/pheniramine/phenylephrine caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation) acetaminophen/phenylephrine caution 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/pseudoephedrine caution 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] acetaminophens caution 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] acyclovir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown) aliskiren/amlodipine monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced)

aliskiren/amlodipine/hydrochlorothiazide monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced) amiodarone monitor levels, efficacy: combo may incr. phenytoin levels, risk of toxicity; decr. amiodarone levels, efficacy (hepatic metab. inhibited; hepatic metab. induced) amlodipine/ARB combos monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced) [amlodipine/ARB combos: amlodipine/olmesartan, amlodipine/valsartan, telmisartan/amlodipine] amlodipine/ARB/thiazide combos monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced) [amlodipine/ARB/thiazide combos: amlodipine/valsartan/hydrochlorothiazide, olmesartan/amlodipine/hydrochlorothiazide] amlodipine/atorvastatin monitor BP, cholesterol levels: combo may decr. both statin and calcium channel blocker levels, efficacy (hepatic metab. induced) antacids give 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] aprepitant caution advised, monitor efficacy: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) [aprepitant: aprepitant, fosaprepitant] aripiprazole adjust aripiprazole dose, may be doubled up to max 30 mg/day: combo may decr. aripiprazole levels, efficacy (hepatic metab. induced) aspirin caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/caffeine caution 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 carbonate give 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/dextromethorphan caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/chlorpheniramine/dextromethorphan/phenylephrine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/chlorpheniramine/phenylephrine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/diphenhydramine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/dipyridamole caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/doxylamine/dextromethorphan/phenylephrine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/phenylephrine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) atazanavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) bexarotene caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) bismuth subcitrate potassium/metronidazole/tetracycline monitor levels: combo w/ metronidazole may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) bismuth subsalicylate/metronidazole/tetracycline monitor levels: combo w/ metronidazole, salicylates may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited, protein binding displacement) bosentan caution advised, monitor phenytoin levels: combo may decr. bosentan levels, decr. phenytoin levels (hepatic metab. induced) butalbital/acetaminophen caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced, incr. toxic acetaminophen metabolite formation) calcitriol monitor efficacy; consider calcitriol dose adjustment: enzyme induction may decr. endogenous calcitriol levels, resulting in incr. supplemental calcitriol requirements (hepatic metab. induced) calcium carbonate/magnesium hydroxide give 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 salts give 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] capecitabine monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown) carbamazepine monitor levels: combo may alter levels of both drugs; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) carisoprodol/aspirin caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) carisoprodol/aspirin/codeine caution 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) carvedilol monitor efficacy: combo may decr. carvedilol levels, efficacy (hepatic metab. induced) caspofungin consider incr. caspofungin dose to 70 mg/day in adults, 70 mg/m^2 in peds: combo may decr. caspofungin levels, efficacy (hepatic metab. induced) chloramphenicol monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) cimetidine monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) cinacalcet monitor iPTH, serum calcium: combo may decr. cinacalcet levels, efficacy (hepatic metab. induced) ciprofloxacin monitor levels: combo may incr. or decr. phenytoin levels (hepatic metab. altered) clarithromycin monitor phenytoin levels: combo may decr. clarithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown) clopidogrel caution advised, monitor phenytoin levels: may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) clozapine caution 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 combos caution 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] colesevelam give phenytoin >4h before; monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (absorption decreased) cyclosporine monitor levels: combo may decr. cyclosporine levels, efficacy (hepatic metab. induced) [cyclosporine: cyclosporine modified, cyclosporine non-modified] darunavir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) diazepam caution 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] digoxin monitor digoxin levels: combo may decr. digoxin levels, efficacy (P-glycoprotein induced) disopyramide monitor levels: combo may decr. disopyramide levels, efficacy (hepatic metab. induced) disulfiram monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) doxorubicins monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown) [doxorubicins: doxorubicin, doxorubicin liposomal] efavirenz caution advised, monitor phenytoin levels: combo may decr. efavirenz levels, efficacy; alter phenytoin levels (hepatic metab. altered) efavirenz/emtricitabine/tenofovir disoproxil caution advised, monitor phenytoin levels: combo w/ efavirenz may alter phenytoin levels; decr. efavirenz levels, efficacy (hepatic metab. altered) erythromycins monitor 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] ethosuximide monitor ethosuximide levels: combo may decr. ethosuximide levels, efficacy; may incr.

risk of CNS depression, psychomotor impairment (hepatic metab. induced; mechanism unknown) exemestane adjust exemestane dose to 50 mg/day: combo may decr. exemestane levels, efficacy (hepatic metab. induced) exenatide monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) ezogabine consider 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 hydroxide give phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased) felbamate monitor phenytoin levels, consider phenytoin dose reduction: combo may incr. phenytoin levels, risk of toxicity; decr. felbamate levels, efficacy (hepatic metab. altered) fenofibrate monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) [fenofibrate: fenofibrate, fenofibrate micronized, fenofibric acid] fluconazole monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fluorouracil monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fluoxetine monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fluvastatin monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fluvoxamine monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fosamprenavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) gefitinib consider incr. gefitinib dose to 500 mg/day: combo may decr. gefitinib levels, efficacy (hepatic metab. induced) gemfibrozil monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

growth hormone monitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) [growth hormone: somatropin (recombinant)] guanfacine consider incr. guanfacine dose: combo may decr. guanfacine levels, efficacy (hepatic metab. induced) imatinib incr. imatinib dose 50%, monitor response: combo may decr. imatinib levels, efficacy (hepatic metab. induced) indinavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) influenza vaccine caution 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] insulins monitor 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] isoniazid monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) itraconazole caution advised, monitor efficacy: combo may decr. antifungal levels, efficacy (hepatic metab. induced) ketoconazole caution advised, monitor phenytoin levels: combo may decr. antifungal levels, efficacy; incr. phenytoin levels, risk of toxicity (hepatic metab. altered) lamotrigine caution 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/clarithromycin monitor phenytoin levels: combo may decr. clarithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown) leflunomide monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) leucovorin caution advised, monitor levels: combo may decr. anticonvulsant levels, efficacy (mechanism unknown) levoleucovorin caution advised, monitor levels: combo may decr. anticonvulsant levels, efficacy (mechanism unknown)

liraglutide monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) lithium monitor levels: combo may incr. lithium levels, risk of toxicity (mechanism unknown) magnesium hydroxide/mineral oil give oral phenytoin 2h before or 4h after: combo w/ antacids may decr. phenytoin levels, efficacy (absorption decreased) magnesium salts give 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] maraviroc adjust 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) mefloquine monitor levels, efficacy: combo may decr. levels, efficacy of both drugs (mechanism unknown, hepatic metab. possibly altered) metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) metformin/sulfonylurea combos monitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects) [metformin/sulfonylurea combos: glipizide/metformin, glyburide/metformin] methadone monitor for efficacy, withdrawal: combo may decr. methadone levels, efficacy; precipitate opioid withdrawal symptoms (hepatic metab. induced) methylphenidate monitor 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] metronidazole monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) miglitol monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) modafinil monitor 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]

nateglinide monitor glucose: combo may decr. nateglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) nelfinavir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) nitazoxanide monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) olanzapine/fluoxetine monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) omeprazole monitor 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/amoxicillin monitor 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) oxcarbazepine monitor 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/aspirin caution 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) paroxetine monitor phenytoin levels, monitor paroxetine efficacy: combo may incr. phenytoin levels, risk of toxicity; may decr. paroxetine levels, efficacy (hepatic metab. altered) phenobarbital monitor levels: combo may decr. levels of both drugs (hepatic metab. induced) phenobarbital/hyoscyamine/atropine/scopolamine monitor levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) pioglitazone monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) pioglitazone/glimepiride monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) pioglitazone/metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia)

primidone monitor levels: combo may incr. phenobarbital levels, decr. phenytoin levels (hepatic metab. induced; incr. conversion of primidone to phenobarbital) propoxyphene/acetaminophen caution 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] quinidine monitor levels: combo may decr. quinidine levels, efficacy (hepatic metab. induced) [quinidine: quinidine gluconate, quinidine sulfate] repaglinide monitor glucose: combo may decr. repaglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) repaglinide/metformin monitor glucose: combo may decr. repaglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) rifampins monitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) [rifampins: rifampin, rifampin/isoniazid, rifampin/isoniazid/pyrazinamide] rifapentine monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) ritonavir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) rosiglitazone monitor glucose: combo may decr. rosiglitazone levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) rosiglitazone/glimepiride monitor glucose: combo may decr. rosiglitazone levels; may decr. hypoglycemic agent efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) rosiglitazone/metformin monitor glucose: combo may decr. rosiglitazone levels; may decr. hypoglycemic agent efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) rufinamide monitor 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-acetylated caution 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] saquinavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) saxagliptin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) saxagliptin/metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) sertraline monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown, hepatic metab. possibly inhibited) sevelamer give anticonvulsant 1h before or 3h after, monitor efficacy: combo may decr. anticonvulsant levels, efficacy (absorption possibly decreased) sitagliptin monitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects) sitagliptin/metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) sitagliptin/simvastatin monitor 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 substrates monitor efficacy: combo may decr. statin levels, efficacy (hepatic metab. induced) [statins, CYP3A4 substrates: atorvastatin, ezetimibe/simvastatin, lovastatin, simvastatin] sucralfate give oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased) sulfonylureas monitor 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] tacrolimus monitor levels: combo may decr. tacrolimus levels, efficacy (hepatic metab. induced) telithromycin monitor phenytoin levels: combo may decr. telithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown) tesamorelin monitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced)

theophyllines monitor levels: combo may decr. theophylline levels, efficacy (hepatic metab. induced) [theophyllines: aminophylline, theophylline] thyroid hormones monitor 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)] tiagabine caution 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) ticlopidine monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) tinidazole monitor levels, efficacy: combo may incr. phenytoin levels, risk of toxicity; decr. tinidazole levels, efficacy (hepatic metab. inhibited; hepatic metab. induced) tipranavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) TNF blocking agents monitor 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] tocilizumab monitor 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) topiramate monitor levels: combo may incr. phenytoin levels, risk of toxicity; decr. topiramate levels, efficacy (hepatic metab. altered) [topiramate: phentermine hydrochloride/topiramate, topiramate] trazodone caution advised, monitor phenytoin levels: combo may decr. trazodone levels, efficacy; may incr. phenytoin levels, risk of toxicity (hepatic metab. induced; mechanism unknown) trimethoprim monitor levels, CBC: combo may incr. phenytoin levels, risk of toxicity, risk of megaloblastic anemia (hepatic metab. inhibited, additive/synergistic folate antagonism) trimethoprim/sulfamethoxazole monitor levels, CBC: combo w/ trimethoprim may incr. phenytoin levels, risk of toxicity, risk of megaloblastic anemia (hepatic metab. inhibited, additive/synergistic folate antagonism)

ustekinumab monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. possibly altered; ustekinumab may normalize hepatic enzyme formation suppressed by incr. cytokine levels) valacyclovir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown) valproic acid derivatives monitor 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] vigabatrin monitor phenytoin levels: combo may decr. phenytoin levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) voriconazole incr. 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) warfarin monitor INR: combo may decr. INR, warfarin efficacy and transiently incr. INR, risk of bleeding (hepatic metab. induced, protein binding displacement) zafirlukast monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

Caution Advised

abiraterone acetate caution advised: combo may decr. abiraterone levels, efficacy (hepatic metab. induced) aldesleukin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) alendronate/cholecalciferol caution advised: combo may decr. cholecalciferol efficacy (hepatic metab. induced) alfentanil caution advised: combo may decr. alfentanil efficacy (hepatic metab. induced) apomorphine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive/synergistic effects) artemether/lumefantrine caution advised: combo may decr. artemether/lumefantrine levels, efficacy (hepatic metab. induced) azelastine nasal caution advised: combo may incr. risk of CNS depression, psychomotor impairment

(additive effects) [azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal] belatacept caution advised: combo may decr. phenytoin levels, efficacy (hepatic metab. possibly altered; belatacept may normalize hepatic enzyme formation suppressed by incr. cytokine levels) benzocaine contraindicated 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 combos contraindicated 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 substrates caution 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, other caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [benzodiazepines, other: clobazam, estazolam, lorazepam, oxazepam, temazepam] black cohosh caution 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] bromocriptine caution advised: combo may decr. bromocriptine levels, efficacy (hepatic metab. induced) budesonide caution advised: combo may decr. budesonide levels, efficacy (hepatic metab. induced) buprenorphine caution advised: combo may decr. buprenorphine levels, efficacy (hepatic metab. induced) [buprenorphine: buprenorphine, buprenorphine transdermal, buprenorphine/naloxone] bupropion caution advised: combo may decr. buproprion efficacy (hepatic metab. induced) [bupropion: bupropion hydrobromide, bupropion hydrochloride]

buspirone caution advised: combo may decr. buspirone levels, efficacy (hepatic metab. induced) busulfan caution advised: combo may decr. busulfan levels, efficacy (hepatic metab. induced) caffeine caution advised: combo may decr. caffeine levels, efficacy (hepatic metab. induced) [caffeine: caffeine, caffeine citrate, caffeine/sodium benzoate] carbidopa/levodopa caution advised: combo may decr. levodopa efficacy (mechanism unknown) carbidopa/levodopa/entacapone caution advised: combo may decr. levodopa efficacy (mechanism unknown) carbonic anhydrase inhibitors, systemic caution advised: combo may incr. risk of osteomalacia (calcium renal excretion increased, metabolic acidosis) [carbonic anhydrase inhibitors, systemic: acetazolamide, methazolamide] chlordiazepoxide caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) clonazepam caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) clorazepate caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) colchicine caution advised: combo may decr. colchicine levels, efficacy (hepatic metab. induced) conivaptan caution advised: combo may decr. conivaptan levels, efficacy (hepatic metab. induced) corticosteroids, systemic caution 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] cyclophosphamide caution advised: combo may incr. cyclophosphamide active metabolite levels, risk of toxicity (hepatic metab. induced, incr. active metabolite formation) dantrolene caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) dapsone caution advised: combo may decr. dapsone levels, efficacy (hepatic metab. induced) darifenacin caution advised: combo may decr. darifenacin levels, efficacy (hepatic metab. induced) dasatinib caution advised: combo may decr. dasatinib levels, efficacy (hepatic metab. induced)

diazoxide caution advised: combo may incr. risk of hyperglycemia; combo w/ PO diazoxide may decr. phenytoin levels, incr. risk of seizures (additive effects; mechanism unknown) diclofenac caution advised: combo may decr. diclofenac levels, efficacy (hepatic metab. induced) [diclofenac: diclofenac potassium, diclofenac sodium, diclofenac/misoprostol] docetaxel caution advised: combo may decr. docetaxel levels, efficacy (hepatic metab. induced) donepezil caution advised: combo may decr. donepezil levels, efficacy (hepatic metab. induced) doxercalciferol caution advised: combo may decr. doxercalciferol efficacy (hepatic metab. induced) doxycycline caution advised, monitor efficacy: combo may decr. doxycycline levels, efficacy (mechanism unknown) eplerenone caution advised: combo may decr. eplerenone levels, efficacy (hepatic metab. induced) ergotamine/caffeine caution advised: combo may decr. caffeine levels, efficacy (hepatic metab. induced) eszopiclone caution advised: combo may decr. eszopiclone levels, efficacy (hepatic metab. induced) ethanol caution 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) fentanyl caution advised: combo may decr. fentanyl levels, efficacy (hepatic metab. induced) [fentanyl: fentanyl, fentanyl nasal, fentanyl transdermal, fentanyl transmucosal] flurazepam caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) gabapentin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [gabapentin: gabapentin, gabapentin enacarbil] green tea caution 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] haloperidol caution advised: combo may decr. haloperidol levels, efficacy (mechanism unknown) [haloperidol: haloperidol, haloperidol decanoate, haloperidol lactate] HRT, estrogen caution 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 combo caution 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, progestin caution advised: combo may decr. progestin levels, efficacy (hepatic metab. induced) [HRT, progestin: medroxyprogesterone, norethindrone acetate] hydromorphone caution 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] ifosfamide caution 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) isotretinoin caution advised: combo may incr. risk of bone loss (additive effects) kava caution 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] ketamine caution advised: combo may decr. ketamine levels, efficacy (hepatic metab. induced) levocetirizine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) levonorgestrel intrauterine device caution advised: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) lidocaine topical contraindicated 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]

linezolid caution advised: combo may decr. linezolid levels, efficacy (mechanism unknown, hepatic metab. possibly induced) meperidine caution advised: combo may decr. meperidine levels, analgesic efficacy, may incr. risk of normeperidine neurotoxicity (hepatic metab. induced, incr. toxic metabolite formation) meprobamate caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) mirtazapine caution advised: combo may decr. mirtazepine levels, effects (hepatic metab. induced) mitotane caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) montelukast caution advised: combo may decr. montelukast levels, efficacy (hepatic metab. induced) morphine liposomal caution advised: combo may incr. risk of CNS depression, profound sedation, hypotension, other adverse effects (additive effects) nafarelin nasal caution advised: combo may incr. risk of bone loss (additive effects) nevirapine caution advised: combo may decr. nevirapine levels, efficacy (hepatic metab. induced) niacin/lovastatin caution advised: combo may decr. lovastatin levels, efficacy (hepatic metab. induced) niacin/simvastatin caution advised: combo may decr. simvastatin levels, efficacy (hepatic metab. induced) nitrites/sodium thiosulfate caution advised: combo w/ nitrites may incr. risk of methemoglobinemia (additive effects) [nitrites/sodium thiosulfate: amyl nitrite/sodium nitrite/sodium thiosulfate, sodium nitrite/sodium thiosulfate] nitroprusside caution advised: combo may incr. risk of methemoglobinemia (additive effects) olopatadine nasal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) oxycodone caution advised, consider dose adjustment: combo may decr. oxycodone levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) oxycodone/ibuprofen caution advised, consider dose adjustment: combo may decr. oxycodone levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

paclitaxel caution advised: combo may decr. paclitaxel levels, efficacy (hepatic metab. induced) [paclitaxel: paclitaxel, paclitaxel nanoparticle albumin-bound] peginterferon alfa 2b caution advised: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) pimozide caution 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) pramipexole caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) pregabalin caution 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] propofol caution advised: combo may incr. risk of CNS depression, psychomotor impairment; may decr. propofol levels, efficacy (additive effects; hepatic metab. induced) [propofol: fospropofol, propofol] propoxyphene caution advised: combo may decr. propoxyphene levels, efficacy, incr. active metabolite formation, risk of toxicity (hepatic metab. induced) [propoxyphene: propoxyphene hydrochloride, propoxyphene napsylate] quetiapine caution advised: combo may decr. quetiapine levels, efficacy (clearance increased) quinine sulfate caution advised: combo may decr. quinine levels, efficacy (hepatic metab. induced) ramelteon caution advised: combo may decr. ramelteon levels, efficacy (hepatic metab. induced) risperidone caution advised: combo may decr. risperidone levels, efficacy (hepatic metab. induced) romidepsin caution advised: combo may decr. romidepsin levels, efficacy (hepatic metab. induced) ropinirole caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) rotigotine transdermal caution advised: combo may incr. phenytoin levels, risk of toxicity; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. inhibited; additive effects)

ruxolitinib caution advised: combo may decr. ruxolitinib levels, efficacy, may incr. active metabolite formation, risk of adverse effects (hepatic metab. induced) selegiline caution advised: combo may decr. selegiline levels, efficacy (hepatic metab. induced) selegiline transdermal caution advised: combo may decr. selegiline levels, efficacy (hepatic metab. induced) sildenafil caution advised: combo may decr. sildenafil levels, efficacy (hepatic metab. induced) sodium oxybate caution advised: combo may incr. risk of CNS depression, other adverse effects (additive effects) solifenacin caution advised: combo may decr. solifenacin levels, efficacy (hepatic metab. induced) sorafenib caution advised, monitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects; decr. sorafenib levels, efficacy (hepatic metab. inhibited; hepatic metab. induced) streptozocin caution advised: combo may decr. streptozocin efficacy (mechanism unknown) sufentanil caution advised: combo may decr. sufentanil efficacy (hepatic metab. induced) tamoxifen caution advised: combo may decr. tamoxifen and active metabolite levels, efficacy (hepatic metab. induced) tapentadol caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) teniposide caution advised: combo may decr. teniposide levels, efficacy (hepatic metab. induced) tetrabenazine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) thiotepa caution advised: combo may decr. thiotepa levels, efficacy; may incr. thiotepa active metabolite levels, risk of toxicity (hepatic metab. induced) toremifene caution advised: combo may decr. toremifene levels, efficacy (hepatic metab. induced) tricyclic antidepressants caution 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] vemurafenib caution advised: combo may decr. vemurafenib levels, efficacy (hepatic metab. induced)

vinca alkaloids caution advised: combo may decr. vinca alkaloid levels, efficacy (hepatic metab. induced) [vinca alkaloids: vinblastine, vincristine, vinorelbine] zaleplon caution advised: combo may decr. zaleplon levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) zolpidem caution advised: combo may decr. zolpidem levels, efficacy (hepatic metab. induced) zonisamide caution 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 Action modulates 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 Genrico: phenytoin (oral) Nombres de las Marcas: Dilantin, Dilantin Infatabs, Dilantin-125, Phenytek

Cul es la informacin ms importante que debo saber sobre phenytoin?

Usted no debe tomar phenytoin si usted tambin est tomando delavirdine (Rescriptor), o si es alrgico a phenytoin, ethotoin (Peganone), fosphenytoin (Cerebyx), o mephenytoin (Mesantoin).

Si usted est embarazada, NO EMPIECE A TOMAR phenytoin salvo que su mdico le haya indicado hacerlo. Phenytoin puede hacer dao al beb nonato, pero tener una convulsin cuando est embarazada le puede hacer dao a la madre y al beb. Si usted queda embarazada mientras est tomando phenytoin, NO DEJE DE TOMAR la medicina sin el consejo de su mdico. 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 mdico necesitar examinarlo con regularidad. No falte a las visitas mdica establecidas por su mdico.

Informe a su mdico de algn sntoma nuevo o que empeora, como: cambios del humor o del comportamiento, depresin, ansiedad, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o de fsico), o tiene pensamientos de suicidio o de querer hacerse dao.

Qu es phenytoin?
Phenytoin es una droga antiepilptica, tambin 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 mdico determinar si es la medicina correcta para usted. Phenytoin puede tambin usarse para fines no mencionados en esta gua del medicamento.

Qu debera discutir con el profesional del cuidado de la salud antes de usar phenytoin?
Usted no debe tomar phenytoin si usted tambin est tomando delavirdine (Rescriptor), o si es alrgico a phenytoin, ethotoin (Peganone), fosphenytoin (Cerebyx), o mephenytoin (Mesantoin). Para asegurarse que usted puede tomar phenytoin de forma segura, dgale a su mdico si usted tiene cualquiera de estas otras condiciones:

enfermedad del hgado; lupus; diabetes; deficiencia de la vitamina D o cualquier otra condicin que desgasta los huesos; porfiria (un trastorno gentico de enzima que causa sntomas 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. Dgale a su mdico si usted tiene sntomas de la depresin 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 tambin deben mantenerse alertas a los cambios en su humor o sntomas. Su mdico necesitar examinarlo con regularidad. No falte a las visitas mdicas establecidas por su mdico. Los pacientes con antepasados de origen Asitico pueden tener un riesgo ms alto de desarrollar una reaccin a la piel, rara, pero de gravedad con phenytoin. Su mdico puede recomendar pruebas de la sangre antes de que empiece la medicina para determinar su riesgo a tener esta reaccin. Categora D del embarazo por la FDA. Phenytoin le puede hacer dao al beb nonato, pero tener una convulsin cuando est embarazada le puede hacer dao a la madre y al beb.

Si usted est embarazada, NO EMPIECE A TOMAR phenytoin salvo que su mdico le haya indicado. Si usted queda embarazada mientras est tomando phenytoin, NO DEJE DE TOMAR la medicina sin el consejo de su mdico. 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 mdico acerca de tomar phenytoin durante su embarazo. Phenytoin puede hacer las pastillas anticonceptivas menos efectivas. Para prevenir el embarazo mientras toma phenytoin, use un mtodo de control de natalidad no hormonal (como el condn o diafragma con espermicida).

Phenytoin puede pasar a la leche materna y causarle dao al beb lactante. Usted no debe amamantar mientras est usando phenytoin.

Cmo debo tomar phenytoin?

Tmelo exactamente cmo lo haya recetado su mdico. No lo tome en cantidades mayores o menores, o por ms tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripcin.

No triture, mastique, rompa, o abra una cpsula de liberacin extendida. Trguelas enteras. Romper o abrir la pldora puede causar que mucha medicina pase al cuerpo de inmediato. No use ninguna cpsula que ha cambiado de color. Llame a su mdico para una nueva prescripcin.

Agite bien la suspensin oral (lquida) antes de medir una dosis. Mida el lquido con una cucharita o taza de medicin, no lo haga con una cuchara normal. Si no tiene con que medir su dosis, pdale una a su farmacutico.

Para estar seguro de que este medicamento est ayudando su condicin, tal vez se necesite examinar su sangre con frecuencia. Tambin puede ser que necesite exmenes de sangre cuando cambie de una presentacin de phenytoin a otra. Visite a su mdico con regularidad.

Si est 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 aprobacin de su mdico. Dgale a su mdico si le parece que su medicina ha dejado de funcionar como lo hacia para el tratamiento de su condicin.

Lleve con usted una tarjeta de identificacin que indique que usted est tomando phenytoin. Cualquier proveedor del cuidado mdico que lo trate debera saber que usted esta usando una medicina para el control de convulsiones.

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

Qu sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome ms medicina para alcanzar la dosis pasada.

Qu sucedera en una sobredosis?

Busque atencin mdica de emergencia o llame a la lnea de Poison Help al 1-800-222-1222. La sobredosis de phenytoin puede ser fatal. Los sntomas de sobredosis pueden incluir movimientos espasmdicos de los ojos, arrastre de las palabras al hablar, perdida del balance, temblores, rigidez muscular o debilidad, nusea, vmito, sentir que se puede desmayar, desmayo, y respiracin lenta o no profunda.

Qu debo evitar mientras uso phenytoin?

Evite beber alcohol mientras est 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 anticidos al mismo tiempo que toma phenytoin. Los anticidos pueden hacer ms difcil para que su cuerpo pueda absorber la medicina.

Phenytoin puede perjudicar su pensamiento o reacciones. Tenga cuidado si usted conduce un vehculo o tenga que hacer algo que demande se mantenga alerta.

Cules son los efectos secundarios posibles de phenytoin?

Busque atencin mdica de emergencia si usted tiene alguno de estos sntomas de una reaccin alrgica: ronchas; dificultad para respirar; hinchazn de su cara, labios, lengua, o garganta. Es ms probable que tenga una reaccin alrgica si es de raza Americana-Africana.

Informe a su mdico de algn sntoma nuevo o que empeora, como: cambios del humor o del comportamiento, depresin, ansiedad, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o de fsico), o tiene pensamientos de suicidio o de querer hacerse dao.

Llame a su mdico de inmediato si usted tiene un efecto secundario grave como:

fiebre, glndulas hinchadas, dolor de cuerpo, sntomas de la gripe; sarpullido, moretones o sangrado fcil, hormigueo severo, entumecimiento, dolor, debilidad muscular; dolor en la parte superior del estmago, prdida del apetito, orina oscura, ictericia (color amarillo de la piel u ojos); dolor de pecho, ritmo cardaco irregular, sensacin de que le falta aire al respirar; confusin, nusea y vmito, hinchazn, ganancia de peso rpida, 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 reaccin severa de la piel -- fiebre, dolor de garganta, hinchazn en su cara o lengua, quemazn en sus ojos, dolor de la piel, seguido por un sarpullido rojo o prpura que se extiende (especialmente en la cara o la parte superior del cuerpo) y causa ampollas y descamacin.

Efectos secundarios de menor gravedad pueden incluir:

habla arrastrado, perdida del balance o coordinacin; encas 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 mdico para consejos mdicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

Qu otras drogas afectarn a phenytoin?

Varias drogas pueden tener interacciones con phenytoin. La lista que se presenta abajo no incluye todas las drogas. Dgale a su mdico si usted est usando:

antibiticos 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 corazn 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 cido del estmago (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. Dgale a su mdico 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 mdico. Mantenga una lista de todas sus medicinas y mustresela a cualquier profesional de la salud que lo atienda.

Dnde puedo obtener ms informacin?

Su farmacutico le puede dar ms informacin acerca de phenytoin (fenitoina).

Drug

phenytoin
generic

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), 1020 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

boceprevir contraindicated: combo may decr. boceprevir levels, efficacy (hepatic metab. induced) delavirdine contraindicated: combo may decr. delavirdine levels, efficacy (hepatic metab. induced) emtricitabine/rilpivirine/tenofovir disoproxil contraindicated: combo may decr. rilpivirine levels, efficacy (hepatic metab. induced) etravirine contraindicated: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) lopinavir/ritonavir contraindicated 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) lurasidone contraindicated: combo may decr. lurasidone levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) praziquantel contraindicated; 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) ranolazine contraindicated: combo may decr. ranolazine levels, efficacy (hepatic metab. induced) rilpivirine contraindicated: combo may decr. rilpivirine levels, efficacy (hepatic metab. induced)

Avoid/Use Alternative

acetaminophen/codeine use 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) axitinib avoid combo: combo may decr. axitinib levels, efficacy (hepatic metab. induced) bortezomib avoid combo: combo may decr. bortezomib levels, efficacy (hepatic metab. induced) bosutinib avoid combo: combo may decr. bosutinib levels, efficacy (hepatic metab. induced) cabazitaxel avoid combo: combo may decr. cabazitaxel levels, efficacy (hepatic metab. induced) calcium channel blockers, dihydropyridines use 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, others use alternative or monitor for efficacy: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced) [calcium channel blockers, others: diltiazem, trandolapril/verapamil, verapamil] cobicistat avoid combo: combo may decr. cobicistat levels, efficacy (hepatic metab. induced) [cobicistat: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil] contraceptives, oral combo caution 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 progestin use additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) [contraceptives, oral progestin: norethindrone] contraceptives, other combo caution 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]

crizotinib avoid combo or use alternative: combo may decr. crizotinib levels, efficacy (hepatic metab. induced) deferasirox avoid 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) dopamine use alternative or monitor BP: combo w/ IV phenytoins may incr. risk of severe hypotension (mechanism unknown, possible additive effects) dronedarone avoid combo: combo may decr. dronedarone levels, efficacy (hepatic metab. induced) elvitegravir avoid combo or use alternative: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) [elvitegravir: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil] enzalutamide avoid combo: combo may decr. levels of both drugs, efficacy (hepatic metab. induced) erlotinib use alternative or consider incr. erlotinib dose >150 mg/day: combo may decr. erlotinib levels (hepatic metab. induced) etonogestrel subdermal implant use additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) everolimus avoid 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 biloba avoid 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/acetaminophen use 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) irinotecan avoid 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) ivacaftor avoid combo: combo may decr. ivacaftor levels, efficacy (hepatic metab. induced)

ixabepilone use alternative: combo may decr. ixabepilone levels, efficacy (hepatic metab. induced) lapatinib avoid 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) levonorgestrel use alternative non-hormonal contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) linagliptin use alternative: combo may decr. linagliptin levels, efficacy (hepatic metab. induced, pglycoprotein induced, antagonistic effects) linagliptin/metformin use alternative: combo may decr. linagliptin levels, efficacy (hepatic metab. induced, Pglycoprotein induced) local anesthetics avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) [local anesthetics: bupivacaine, bupivacaine liposomal, chloroprocaine, lidocaine, mepivacaine, procaine, ropivacaine] local anesthetics/epinephrine avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) [local anesthetics/epinephrine: articaine/epinephrine] medroxyprogesterone acetate use additional non-hormonal or alternative contraception: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) methotrexate use alternative or monitor efficacy, toxicity, levels: combo may incr. methotrexate toxicity and decr. efficacy; may decr. phenytoin levels, efficacy (mechanism unknown; absorption decreased) mifepristone avoid combo if daily mifepristone use; caution advised if pregnancy termination use: combo may decr. mifepristone levels, efficacy (hepatic metab. induced) milk thistle avoid 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] nilotinib avoid 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/acetaminophen use 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) pazopanib contraindicated if chronic use of strong CYP3A4 inducer, otherwise avoid combo or use alternative: combo may decr. pazopanib levels, efficacy (hepatic metab. induced) pentazocine/acetaminophen use 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) posaconazole weigh risk/benefit, monitor phenytoin levels: combo may decr. posaconazole levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. altered) rivaroxaban avoid combo: combo may decr. rivaroxaban levels, efficacy (hepatic metab. induced, Pglycoprotein induced) roflumilast avoid combo: combo may decr. roflumilast levels, efficacy (hepatic metab. induced) sunitinib use 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) tadalafil avoid combo in pulmonary HTN pts; caution advised for ED pts: combo may decr. tadalafil levels, efficacy (hepatic metab. induced) telaprevir avoid 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) temsirolimus avoid combo or consider incr. temsirolimus dose to 50 mg/wk: combo may decr. temsirolimus and sirolimus levels, efficacy (hepatic metab. induced) ticagrelor avoid combo: combo may decr. ticagrelor levels, efficacy (hepatic metab. induced) tolvaptan avoid combo or consider incr. tolvaptan dose: combo may decr. tolvaptan levels, efficacy (hepatic metab. induced) tramadol avoid 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/acetaminophen use 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) ulipristal use alternative non-hormonal contraception: combo may decr. ulipristal levels, contraceptive efficacy (hepatic metab. induced) vandetanib avoid combo: combo may decr. vandetanib levels, efficacy (hepatic metab. induced)

Monitor/Modify Tx

acarbose monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) acetaminophen/aspirin caution 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/caffeine caution 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/caffeine caution 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 combos caution 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/chlorpheniramine caution 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 caution 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/phenylephrine caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation)

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

acetaminophen/pheniramine/phenylephrine caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced; incr. toxic metabolite formation) acetaminophen/phenylephrine caution 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/pseudoephedrine caution 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] acetaminophens caution 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] acyclovir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown) aliskiren/amlodipine monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced) aliskiren/amlodipine/hydrochlorothiazide monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced) amiodarone monitor levels, efficacy: combo may incr. phenytoin levels, risk of toxicity; decr. amiodarone levels, efficacy (hepatic metab. inhibited; hepatic metab. induced) amlodipine/ARB combos monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced) [amlodipine/ARB combos: amlodipine/olmesartan, amlodipine/valsartan, telmisartan/amlodipine] amlodipine/ARB/thiazide combos monitor BP: combo may decr. calcium channel blocker levels, efficacy (hepatic metab. induced) [amlodipine/ARB/thiazide combos: amlodipine/valsartan/hydrochlorothiazide, olmesartan/amlodipine/hydrochlorothiazide] amlodipine/atorvastatin monitor BP, cholesterol levels: combo may decr. both statin and calcium channel blocker levels, efficacy (hepatic metab. induced) antacids give 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] aprepitant caution advised, monitor efficacy: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) [aprepitant: aprepitant, fosaprepitant] aripiprazole adjust aripiprazole dose, may be doubled up to max 30 mg/day: combo may decr. aripiprazole levels, efficacy (hepatic metab. induced) aspirin caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/caffeine caution 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 carbonate give 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/dextromethorphan caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/chlorpheniramine/dextromethorphan/phenylephrine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/chlorpheniramine/phenylephrine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/diphenhydramine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/dipyridamole caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/doxylamine/dextromethorphan/phenylephrine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) aspirin/phenylephrine caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) atazanavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced)

bexarotene caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) bismuth subcitrate potassium/metronidazole/tetracycline monitor levels: combo w/ metronidazole may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) bismuth subsalicylate/metronidazole/tetracycline monitor levels: combo w/ metronidazole, salicylates may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited, protein binding displacement) bosentan caution advised, monitor phenytoin levels: combo may decr. bosentan levels, decr. phenytoin levels (hepatic metab. induced) butalbital/acetaminophen caution advised, limit acetaminophen <2 g/day: combo may incr. risk of acetaminophen toxicity, decr. efficacy (hepatic metab. induced, incr. toxic acetaminophen metabolite formation) calcitriol monitor efficacy; consider calcitriol dose adjustment: enzyme induction may decr. endogenous calcitriol levels, resulting in incr. supplemental calcitriol requirements (hepatic metab. induced) calcium carbonate/magnesium hydroxide give 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 salts give 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] capecitabine monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown) carbamazepine monitor levels: combo may alter levels of both drugs; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) carisoprodol/aspirin caution advised, especially w/ high dose aspirin or salicylates, monitor levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) carisoprodol/aspirin/codeine caution 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) carvedilol monitor efficacy: combo may decr. carvedilol levels, efficacy (hepatic metab. induced)

caspofungin consider incr. caspofungin dose to 70 mg/day in adults, 70 mg/m^2 in peds: combo may decr. caspofungin levels, efficacy (hepatic metab. induced) chloramphenicol monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) cimetidine monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) cinacalcet monitor iPTH, serum calcium: combo may decr. cinacalcet levels, efficacy (hepatic metab. induced) ciprofloxacin monitor levels: combo may incr. or decr. phenytoin levels (hepatic metab. altered) clarithromycin monitor phenytoin levels: combo may decr. clarithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown) clopidogrel caution advised, monitor phenytoin levels: may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) clozapine caution 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 combos caution 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] colesevelam give phenytoin >4h before; monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (absorption decreased) cyclosporine monitor levels: combo may decr. cyclosporine levels, efficacy (hepatic metab. induced) [cyclosporine: cyclosporine modified, cyclosporine non-modified] darunavir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) diazepam caution 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] digoxin monitor digoxin levels: combo may decr. digoxin levels, efficacy (P-glycoprotein induced)

disopyramide monitor levels: combo may decr. disopyramide levels, efficacy (hepatic metab. induced) disulfiram monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) doxorubicins monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown) [doxorubicins: doxorubicin, doxorubicin liposomal] efavirenz caution advised, monitor phenytoin levels: combo may decr. efavirenz levels, efficacy; alter phenytoin levels (hepatic metab. altered) efavirenz/emtricitabine/tenofovir disoproxil caution advised, monitor phenytoin levels: combo w/ efavirenz may alter phenytoin levels; decr. efavirenz levels, efficacy (hepatic metab. altered) erythromycins monitor 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] ethosuximide monitor ethosuximide levels: combo may decr. ethosuximide levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; mechanism unknown) exemestane adjust exemestane dose to 50 mg/day: combo may decr. exemestane levels, efficacy (hepatic metab. induced) exenatide monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) ezogabine consider 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 hydroxide give phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased) felbamate monitor phenytoin levels, consider phenytoin dose reduction: combo may incr. phenytoin levels, risk of toxicity; decr. felbamate levels, efficacy (hepatic metab. altered) fenofibrate monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) [fenofibrate: fenofibrate, fenofibrate micronized, fenofibric acid]

fluconazole monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fluorouracil monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fluoxetine monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fluvastatin monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fluvoxamine monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) fosamprenavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) gefitinib consider incr. gefitinib dose to 500 mg/day: combo may decr. gefitinib levels, efficacy (hepatic metab. induced) gemfibrozil monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) growth hormone monitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) [growth hormone: somatropin (recombinant)] guanfacine consider incr. guanfacine dose: combo may decr. guanfacine levels, efficacy (hepatic metab. induced) imatinib incr. imatinib dose 50%, monitor response: combo may decr. imatinib levels, efficacy (hepatic metab. induced) indinavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) influenza vaccine caution 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] insulins monitor 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]

isoniazid monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) itraconazole caution advised, monitor efficacy: combo may decr. antifungal levels, efficacy (hepatic metab. induced) ketoconazole caution advised, monitor phenytoin levels: combo may decr. antifungal levels, efficacy; incr. phenytoin levels, risk of toxicity (hepatic metab. altered) lamotrigine caution 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/clarithromycin monitor phenytoin levels: combo may decr. clarithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown) leflunomide monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) leucovorin caution advised, monitor levels: combo may decr. anticonvulsant levels, efficacy (mechanism unknown) levoleucovorin caution advised, monitor levels: combo may decr. anticonvulsant levels, efficacy (mechanism unknown) liraglutide monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) lithium monitor levels: combo may incr. lithium levels, risk of toxicity (mechanism unknown) magnesium hydroxide/mineral oil give oral phenytoin 2h before or 4h after: combo w/ antacids may decr. phenytoin levels, efficacy (absorption decreased) magnesium salts give 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] maraviroc adjust 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) mefloquine monitor levels, efficacy: combo may decr. levels, efficacy of both drugs (mechanism unknown, hepatic metab. possibly altered)

metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) metformin/sulfonylurea combos monitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects) [metformin/sulfonylurea combos: glipizide/metformin, glyburide/metformin] methadone monitor for efficacy, withdrawal: combo may decr. methadone levels, efficacy; precipitate opioid withdrawal symptoms (hepatic metab. induced) methylphenidate monitor 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] metronidazole monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) miglitol monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) modafinil monitor 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] nateglinide monitor glucose: combo may decr. nateglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) nelfinavir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) nitazoxanide monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (protein binding displacement) olanzapine/fluoxetine monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) omeprazole monitor 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/amoxicillin monitor 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)

oxcarbazepine monitor 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/aspirin caution 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) paroxetine monitor phenytoin levels, monitor paroxetine efficacy: combo may incr. phenytoin levels, risk of toxicity; may decr. paroxetine levels, efficacy (hepatic metab. altered) phenobarbital monitor levels: combo may decr. levels of both drugs (hepatic metab. induced) phenobarbital/hyoscyamine/atropine/scopolamine monitor levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) pioglitazone monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) pioglitazone/glimepiride monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) pioglitazone/metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) primidone monitor levels: combo may incr. phenobarbital levels, decr. phenytoin levels (hepatic metab. induced; incr. conversion of primidone to phenobarbital) propoxyphene/acetaminophen caution 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] quinidine monitor levels: combo may decr. quinidine levels, efficacy (hepatic metab. induced) [quinidine: quinidine gluconate, quinidine sulfate] repaglinide monitor glucose: combo may decr. repaglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) repaglinide/metformin monitor glucose: combo may decr. repaglinide levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia)

rifampins monitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) [rifampins: rifampin, rifampin/isoniazid, rifampin/isoniazid/pyrazinamide] rifapentine monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) ritonavir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) rosiglitazone monitor glucose: combo may decr. rosiglitazone levels, efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) rosiglitazone/glimepiride monitor glucose: combo may decr. rosiglitazone levels; may decr. hypoglycemic agent efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) rosiglitazone/metformin monitor glucose: combo may decr. rosiglitazone levels; may decr. hypoglycemic agent efficacy (hepatic metab. induced; antagonistic effects, phenytoins may cause hyperglycemia) rufinamide monitor 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-acetylated caution 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] saquinavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) saxagliptin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) saxagliptin/metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) sertraline monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (mechanism unknown, hepatic metab. possibly inhibited) sevelamer give anticonvulsant 1h before or 3h after, monitor efficacy: combo may decr. anticonvulsant levels, efficacy (absorption possibly decreased)

sitagliptin monitor glucose: combo may decr. hypoglycemic agent efficacy; phenytoins may cause hyperglycemia (antagonistic effects) sitagliptin/metformin monitor glucose: combo may decr. hypoglycemic agent efficacy (antagonistic effects, phenytoins may cause hyperglycemia) sitagliptin/simvastatin monitor 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 substrates monitor efficacy: combo may decr. statin levels, efficacy (hepatic metab. induced) [statins, CYP3A4 substrates: atorvastatin, ezetimibe/simvastatin, lovastatin, simvastatin] sucralfate give oral phenytoin 2h before or 4h after: combo may decr. phenytoin levels, efficacy (absorption decreased) sulfonylureas monitor 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] tacrolimus monitor levels: combo may decr. tacrolimus levels, efficacy (hepatic metab. induced) telithromycin monitor phenytoin levels: combo may decr. telithromycin levels, efficacy; may incr. phenytoin levels, risk of adverse effects (hepatic metab. induced; mechanism unknown) tesamorelin monitor levels: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) theophyllines monitor levels: combo may decr. theophylline levels, efficacy (hepatic metab. induced) [theophyllines: aminophylline, theophylline] thyroid hormones monitor 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)] tiagabine caution 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) ticlopidine monitor levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) tinidazole monitor levels, efficacy: combo may incr. phenytoin levels, risk of toxicity; decr. tinidazole levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

tipranavir caution advised, monitor phenytoin levels: combo may decr. levels, efficacy of both drugs (hepatic metab. induced) TNF blocking agents monitor 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] tocilizumab monitor 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) topiramate monitor levels: combo may incr. phenytoin levels, risk of toxicity; decr. topiramate levels, efficacy (hepatic metab. altered) [topiramate: phentermine hydrochloride/topiramate, topiramate] trazodone caution advised, monitor phenytoin levels: combo may decr. trazodone levels, efficacy; may incr. phenytoin levels, risk of toxicity (hepatic metab. induced; mechanism unknown) trimethoprim monitor levels, CBC: combo may incr. phenytoin levels, risk of toxicity, risk of megaloblastic anemia (hepatic metab. inhibited, additive/synergistic folate antagonism) trimethoprim/sulfamethoxazole monitor levels, CBC: combo w/ trimethoprim may incr. phenytoin levels, risk of toxicity, risk of megaloblastic anemia (hepatic metab. inhibited, additive/synergistic folate antagonism) ustekinumab monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (hepatic metab. possibly altered; ustekinumab may normalize hepatic enzyme formation suppressed by incr. cytokine levels) valacyclovir monitor phenytoin levels: combo may decr. phenytoin levels, efficacy (mechanism unknown) valproic acid derivatives monitor 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] vigabatrin monitor phenytoin levels: combo may decr. phenytoin levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) voriconazole incr. 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) warfarin monitor INR: combo may decr. INR, warfarin efficacy and transiently incr. INR, risk of bleeding (hepatic metab. induced, protein binding displacement) zafirlukast monitor phenytoin levels: combo may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited)

Caution Advised

abiraterone acetate caution advised: combo may decr. abiraterone levels, efficacy (hepatic metab. induced) aldesleukin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) alendronate/cholecalciferol caution advised: combo may decr. cholecalciferol efficacy (hepatic metab. induced) alfentanil caution advised: combo may decr. alfentanil efficacy (hepatic metab. induced) apomorphine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive/synergistic effects) artemether/lumefantrine caution advised: combo may decr. artemether/lumefantrine levels, efficacy (hepatic metab. induced) azelastine nasal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal] belatacept caution advised: combo may decr. phenytoin levels, efficacy (hepatic metab. possibly altered; belatacept may normalize hepatic enzyme formation suppressed by incr. cytokine levels) benzocaine contraindicated 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 combos contraindicated 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 substrates caution 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, other caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [benzodiazepines, other: clobazam, estazolam, lorazepam, oxazepam, temazepam] black cohosh caution 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] bromocriptine caution advised: combo may decr. bromocriptine levels, efficacy (hepatic metab. induced) budesonide caution advised: combo may decr. budesonide levels, efficacy (hepatic metab. induced) buprenorphine caution advised: combo may decr. buprenorphine levels, efficacy (hepatic metab. induced) [buprenorphine: buprenorphine, buprenorphine transdermal, buprenorphine/naloxone] bupropion caution advised: combo may decr. buproprion efficacy (hepatic metab. induced) [bupropion: bupropion hydrobromide, bupropion hydrochloride] buspirone caution advised: combo may decr. buspirone levels, efficacy (hepatic metab. induced) busulfan caution advised: combo may decr. busulfan levels, efficacy (hepatic metab. induced) caffeine caution advised: combo may decr. caffeine levels, efficacy (hepatic metab. induced) [caffeine: caffeine, caffeine citrate, caffeine/sodium benzoate] carbidopa/levodopa caution advised: combo may decr. levodopa efficacy (mechanism unknown) carbidopa/levodopa/entacapone caution advised: combo may decr. levodopa efficacy (mechanism unknown) carbonic anhydrase inhibitors, systemic caution advised: combo may incr. risk of osteomalacia (calcium renal excretion increased, metabolic acidosis) [carbonic anhydrase inhibitors, systemic: acetazolamide, methazolamide] chlordiazepoxide caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects)

clonazepam caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) clorazepate caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) colchicine caution advised: combo may decr. colchicine levels, efficacy (hepatic metab. induced) conivaptan caution advised: combo may decr. conivaptan levels, efficacy (hepatic metab. induced) corticosteroids, systemic caution 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] cyclophosphamide caution advised: combo may incr. cyclophosphamide active metabolite levels, risk of toxicity (hepatic metab. induced, incr. active metabolite formation) dantrolene caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) dapsone caution advised: combo may decr. dapsone levels, efficacy (hepatic metab. induced) darifenacin caution advised: combo may decr. darifenacin levels, efficacy (hepatic metab. induced) dasatinib caution advised: combo may decr. dasatinib levels, efficacy (hepatic metab. induced) diazoxide caution advised: combo may incr. risk of hyperglycemia; combo w/ PO diazoxide may decr. phenytoin levels, incr. risk of seizures (additive effects; mechanism unknown) diclofenac caution advised: combo may decr. diclofenac levels, efficacy (hepatic metab. induced) [diclofenac: diclofenac potassium, diclofenac sodium, diclofenac/misoprostol] docetaxel caution advised: combo may decr. docetaxel levels, efficacy (hepatic metab. induced) donepezil caution advised: combo may decr. donepezil levels, efficacy (hepatic metab. induced) doxercalciferol caution advised: combo may decr. doxercalciferol efficacy (hepatic metab. induced) doxycycline caution advised, monitor efficacy: combo may decr. doxycycline levels, efficacy (mechanism unknown) eplerenone caution advised: combo may decr. eplerenone levels, efficacy (hepatic metab. induced)

ergotamine/caffeine caution advised: combo may decr. caffeine levels, efficacy (hepatic metab. induced) eszopiclone caution advised: combo may decr. eszopiclone levels, efficacy (hepatic metab. induced) ethanol caution 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) fentanyl caution advised: combo may decr. fentanyl levels, efficacy (hepatic metab. induced) [fentanyl: fentanyl, fentanyl nasal, fentanyl transdermal, fentanyl transmucosal] flurazepam caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) gabapentin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [gabapentin: gabapentin, gabapentin enacarbil] green tea caution 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] haloperidol caution advised: combo may decr. haloperidol levels, efficacy (mechanism unknown) [haloperidol: haloperidol, haloperidol decanoate, haloperidol lactate] HRT, estrogen caution 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 combo caution 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, progestin caution advised: combo may decr. progestin levels, efficacy (hepatic metab. induced) [HRT, progestin: medroxyprogesterone, norethindrone acetate] hydromorphone caution 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] ifosfamide caution 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) isotretinoin caution advised: combo may incr. risk of bone loss (additive effects) kava caution 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] ketamine caution advised: combo may decr. ketamine levels, efficacy (hepatic metab. induced) levocetirizine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) levonorgestrel intrauterine device caution advised: combo may decr. hormonal contraceptive levels, efficacy (hepatic metab. induced) lidocaine topical contraindicated 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] linezolid caution advised: combo may decr. linezolid levels, efficacy (mechanism unknown, hepatic metab. possibly induced) meperidine caution advised: combo may decr. meperidine levels, analgesic efficacy, may incr. risk of normeperidine neurotoxicity (hepatic metab. induced, incr. toxic metabolite formation) meprobamate caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) mirtazapine caution advised: combo may decr. mirtazepine levels, effects (hepatic metab. induced) mitotane caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) montelukast caution advised: combo may decr. montelukast levels, efficacy (hepatic metab. induced)

morphine liposomal caution advised: combo may incr. risk of CNS depression, profound sedation, hypotension, other adverse effects (additive effects) nafarelin nasal caution advised: combo may incr. risk of bone loss (additive effects) nevirapine caution advised: combo may decr. nevirapine levels, efficacy (hepatic metab. induced) niacin/lovastatin caution advised: combo may decr. lovastatin levels, efficacy (hepatic metab. induced) niacin/simvastatin caution advised: combo may decr. simvastatin levels, efficacy (hepatic metab. induced) nitrites/sodium thiosulfate caution advised: combo w/ nitrites may incr. risk of methemoglobinemia (additive effects) [nitrites/sodium thiosulfate: amyl nitrite/sodium nitrite/sodium thiosulfate, sodium nitrite/sodium thiosulfate] nitroprusside caution advised: combo may incr. risk of methemoglobinemia (additive effects) olopatadine nasal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) oxycodone caution advised, consider dose adjustment: combo may decr. oxycodone levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) oxycodone/ibuprofen caution advised, consider dose adjustment: combo may decr. oxycodone levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) paclitaxel caution advised: combo may decr. paclitaxel levels, efficacy (hepatic metab. induced) [paclitaxel: paclitaxel, paclitaxel nanoparticle albumin-bound] peginterferon alfa 2b caution advised: combo may decr. phenytoin levels, efficacy (hepatic metab. induced) pimozide caution 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) pramipexole caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) pregabalin caution 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] propofol caution advised: combo may incr. risk of CNS depression, psychomotor impairment; may decr. propofol levels, efficacy (additive effects; hepatic metab. induced) [propofol: fospropofol, propofol] propoxyphene caution advised: combo may decr. propoxyphene levels, efficacy, incr. active metabolite formation, risk of toxicity (hepatic metab. induced) [propoxyphene: propoxyphene hydrochloride, propoxyphene napsylate] quetiapine caution advised: combo may decr. quetiapine levels, efficacy (clearance increased) quinine sulfate caution advised: combo may decr. quinine levels, efficacy (hepatic metab. induced) ramelteon caution advised: combo may decr. ramelteon levels, efficacy (hepatic metab. induced) risperidone caution advised: combo may decr. risperidone levels, efficacy (hepatic metab. induced) romidepsin caution advised: combo may decr. romidepsin levels, efficacy (hepatic metab. induced) ropinirole caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) rotigotine transdermal caution advised: combo may incr. phenytoin levels, risk of toxicity; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. inhibited; additive effects) ruxolitinib caution advised: combo may decr. ruxolitinib levels, efficacy, may incr. active metabolite formation, risk of adverse effects (hepatic metab. induced) selegiline caution advised: combo may decr. selegiline levels, efficacy (hepatic metab. induced) selegiline transdermal caution advised: combo may decr. selegiline levels, efficacy (hepatic metab. induced) sildenafil caution advised: combo may decr. sildenafil levels, efficacy (hepatic metab. induced) sodium oxybate caution advised: combo may incr. risk of CNS depression, other adverse effects (additive effects) solifenacin caution advised: combo may decr. solifenacin levels, efficacy (hepatic metab. induced) sorafenib caution advised, monitor phenytoin levels: combo may incr. phenytoin levels, risk of adverse effects; decr. sorafenib levels, efficacy (hepatic metab. inhibited; hepatic metab. induced)

streptozocin caution advised: combo may decr. streptozocin efficacy (mechanism unknown) sufentanil caution advised: combo may decr. sufentanil efficacy (hepatic metab. induced) tamoxifen caution advised: combo may decr. tamoxifen and active metabolite levels, efficacy (hepatic metab. induced) tapentadol caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) teniposide caution advised: combo may decr. teniposide levels, efficacy (hepatic metab. induced) tetrabenazine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) thiotepa caution advised: combo may decr. thiotepa levels, efficacy; may incr. thiotepa active metabolite levels, risk of toxicity (hepatic metab. induced) toremifene caution advised: combo may decr. toremifene levels, efficacy (hepatic metab. induced) tricyclic antidepressants caution 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] vemurafenib caution advised: combo may decr. vemurafenib levels, efficacy (hepatic metab. induced) vinca alkaloids caution advised: combo may decr. vinca alkaloid levels, efficacy (hepatic metab. induced) [vinca alkaloids: vinblastine, vincristine, vinorelbine] zaleplon caution advised: combo may decr. zaleplon levels, efficacy; incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) zolpidem caution advised: combo may decr. zolpidem levels, efficacy (hepatic metab. induced) zonisamide caution 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: 710 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 Action modulates 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 Genrico: phenytoin (oral) Nombres de las Marcas: Dilantin, Dilantin Infatabs, Dilantin-125, Phenytek

Cul es la informacin ms importante que debo saber sobre phenytoin?

Usted no debe tomar phenytoin si usted tambin est tomando delavirdine (Rescriptor), o si es alrgico a phenytoin, ethotoin (Peganone), fosphenytoin (Cerebyx), o mephenytoin (Mesantoin).

Si usted est embarazada, NO EMPIECE A TOMAR phenytoin salvo que su mdico le haya indicado hacerlo. Phenytoin puede hacer dao al beb nonato, pero tener una convulsin cuando est embarazada le puede hacer dao a la madre y al beb. Si usted queda embarazada mientras est tomando phenytoin, NO DEJE DE TOMAR la medicina sin el consejo de su mdico. 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 mdico necesitar examinarlo con regularidad. No falte a las visitas mdica establecidas por su mdico.

Informe a su mdico de algn sntoma nuevo o que empeora, como: cambios del humor o del comportamiento, depresin, ansiedad, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o de fsico), o tiene pensamientos de suicidio o de querer hacerse dao.

Qu es phenytoin?
Phenytoin es una droga antiepilptica, tambin 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 mdico determinar si es la medicina correcta para usted. Phenytoin puede tambin usarse para fines no mencionados en esta gua del medicamento.

Qu debera discutir con el profesional del cuidado de la salud antes de usar phenytoin?
Usted no debe tomar phenytoin si usted tambin est tomando delavirdine (Rescriptor), o si es alrgico a phenytoin, ethotoin (Peganone), fosphenytoin (Cerebyx), o mephenytoin (Mesantoin). Para asegurarse que usted puede tomar phenytoin de forma segura, dgale a su mdico si usted tiene cualquiera de estas otras condiciones:

enfermedad del hgado; lupus; diabetes; deficiencia de la vitamina D o cualquier otra condicin que desgasta los huesos; porfiria (un trastorno gentico de enzima que causa sntomas 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. Dgale a su mdico si usted tiene sntomas de la depresin 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 tambin deben mantenerse alertas a los cambios en su humor o sntomas. Su mdico necesitar examinarlo con regularidad. No falte a las visitas mdicas establecidas por su mdico. Los pacientes con antepasados de origen Asitico pueden tener un riesgo ms alto de desarrollar una reaccin a la piel, rara, pero de gravedad con phenytoin. Su mdico puede recomendar pruebas de la sangre antes de que empiece la medicina para determinar su riesgo a tener esta reaccin. Categora D del embarazo por la FDA. Phenytoin le puede hacer dao al beb nonato, pero tener una convulsin cuando est embarazada le puede hacer dao a la madre y al beb.

Si usted est embarazada, NO EMPIECE A TOMAR phenytoin salvo que su mdico le haya indicado. Si usted queda embarazada mientras est tomando phenytoin, NO DEJE DE TOMAR la medicina sin el consejo de su mdico. 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 mdico acerca de tomar phenytoin durante su embarazo.

Phenytoin puede hacer las pastillas anticonceptivas menos efectivas. Para prevenir el embarazo mientras toma phenytoin, use un mtodo de control de natalidad no hormonal (como el condn o diafragma con espermicida).

Phenytoin puede pasar a la leche materna y causarle dao al beb lactante. Usted no debe amamantar mientras est usando phenytoin.

Cmo debo tomar phenytoin?

Tmelo exactamente cmo lo haya recetado su mdico. No lo tome en cantidades mayores o menores, o por ms tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripcin.

No triture, mastique, rompa, o abra una cpsula de liberacin extendida. Trguelas enteras. Romper o abrir la pldora puede causar que mucha medicina pase al cuerpo de inmediato. No use ninguna cpsula que ha cambiado de color. Llame a su mdico para una nueva prescripcin.

Agite bien la suspensin oral (lquida) antes de medir una dosis. Mida el lquido con una cucharita o taza de medicin, no lo haga con una cuchara normal. Si no tiene con que medir su dosis, pdale una a su farmacutico. Para estar seguro de que este medicamento est ayudando su condicin, tal vez se necesite examinar su sangre con frecuencia. Tambin puede ser que necesite exmenes de sangre cuando cambie de una presentacin de phenytoin a otra. Visite a su mdico con regularidad.

Si est 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 aprobacin de su mdico. Dgale a su mdico si le parece que su medicina ha dejado de funcionar como lo hacia para el tratamiento de su condicin.

Lleve con usted una tarjeta de identificacin que indique que usted est tomando phenytoin. Cualquier proveedor del cuidado mdico que lo trate debera saber que usted esta usando una medicina para el control de convulsiones.

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

Qu sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome ms medicina para alcanzar la dosis pasada.

Qu sucedera en una sobredosis?

Busque atencin mdica de emergencia o llame a la lnea de Poison Help al 1-800-222-1222. La sobredosis de phenytoin puede ser fatal. Los sntomas de sobredosis pueden incluir movimientos espasmdicos de los ojos, arrastre de las palabras al hablar, perdida del balance, temblores, rigidez muscular o debilidad, nusea, vmito, sentir que se puede desmayar, desmayo, y respiracin lenta o no profunda.

Qu debo evitar mientras uso phenytoin?

Evite beber alcohol mientras est 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 anticidos al mismo tiempo que toma phenytoin. Los anticidos pueden hacer ms difcil para que su cuerpo pueda absorber la medicina.

Phenytoin puede perjudicar su pensamiento o reacciones. Tenga cuidado si usted conduce un vehculo o tenga que hacer algo que demande se mantenga alerta.

Cules son los efectos secundarios posibles de phenytoin?

Busque atencin mdica de emergencia si usted tiene alguno de estos sntomas de una reaccin alrgica: ronchas; dificultad para respirar; hinchazn de su cara, labios, lengua, o garganta. Es ms probable que tenga una reaccin alrgica si es de raza Americana-Africana.

Informe a su mdico de algn sntoma nuevo o que empeora, como: cambios del humor o del comportamiento, depresin, ansiedad, o si se siente agitado, hostil, inquieto, hiperactivo (de mente o de fsico), o tiene pensamientos de suicidio o de querer hacerse dao.

Llame a su mdico de inmediato si usted tiene un efecto secundario grave como:

fiebre, glndulas hinchadas, dolor de cuerpo, sntomas de la gripe;

sarpullido, moretones o sangrado fcil, hormigueo severo, entumecimiento, dolor, debilidad muscular; dolor en la parte superior del estmago, prdida del apetito, orina oscura, ictericia (color amarillo de la piel u ojos); dolor de pecho, ritmo cardaco irregular, sensacin de que le falta aire al respirar; confusin, nusea y vmito, hinchazn, ganancia de peso rpida, 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 reaccin severa de la piel -- fiebre, dolor de garganta, hinchazn en su cara o lengua, quemazn en sus ojos, dolor de la piel, seguido por un sarpullido rojo o prpura que se extiende (especialmente en la cara o la parte superior del cuerpo) y causa ampollas y descamacin.

Efectos secundarios de menor gravedad pueden incluir:

habla arrastrado, perdida del balance o coordinacin; encas 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 mdico para consejos mdicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

Qu otras drogas afectarn a phenytoin?

Varias drogas pueden tener interacciones con phenytoin. La lista que se presenta abajo no incluye todas las drogas. Dgale a su mdico si usted est usando:

antibiticos 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 corazn 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 cido del estmago (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. Dgale a su mdico 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 mdico. Mantenga una lista de todas sus medicinas y mustresela a cualquier profesional de la salud que lo atienda.

Dnde puedo obtener ms informacin?

Su farmacutico le puede dar ms informacin acerca de phenytoin.

Drug

lidocaine
generic

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

dronedarone contraindicated: combo may incr. lidocaine levels, risk of adverse effects, including QT prolongation, cardiac arrhythmias (hepatic metab. inhibited, additive prolonged QT) morphine liposomal contraindicated 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/aspirin avoid combo or use alternative: combo of local anesthetics and acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/aspirin/caffeine avoid combo or use alternative: combo of local anesthetics and acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/caffeine avoid combo or use alternative: combo of local anesthetics and acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/caffeine/CNS depressant combos avoid 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/chlorpheniramine avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/chlorpheniramine/dextromethorphan avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/chlorpheniramine/dextromethorphan/phenylephrine avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/chlorpheniramine/phenylephrine avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects)

acetaminophen/dextromethorphan avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/dextromethorphan/phenylephrine avoid 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/pseudoephedrine avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) [acetaminophen/dextromethorphan/pseudoephedrine: acetaminophen/dextromethorphan/pseudoephedrine/guaifenesin] acetaminophen/diphenhydramine avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/diphenhydramine/dextromethorphan avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/diphenhydramine/phenylephrine avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/doxylamine/dextromethorphan avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/doxylamine/dextromethorphan/phenylephrine avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/doxylamine/dextromethorphan/pseudoephedrine avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/doxylamine/phenylephrine avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/magnesium salicylate/pamabrom avoid combo or use alternative: combo of local anesthetics and acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/pamabrom avoid combo or use alternative: combo of local anesthetics and acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/pheniramine/phenylephrine avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) acetaminophen/phenylephrine avoid combo or use alternative: combo w/ acetaminophen may incr. risk of

methemoglobinemia (additive effects) [acetaminophen/phenylephrine: acetaminophen/phenylephrine, acetaminophen/phenylephrine/guaifenesin] acetaminophen/pseudoephedrine avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) [acetaminophen/pseudoephedrine: acetaminophen/pseudoephedrine/guaifenesin] acetaminophens avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) [acetaminophens: acetaminophen, acetaminophen rectal, acetaminophen/guaifenesin, isometheptene/dichloralphenazone/acetaminophen] amiodarone weigh 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/acetaminophen avoid combo or use alternative: combo w/ acetaminophen may incr. risk of methemoglobinemia (additive effects) chloroquine phosphate avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) dapsone avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) disopyramide weigh risk/benefit: combo may incr. risk of QT prolongation, cardiac arrhythmias (additive effects) erythromycin/sulfisoxazole avoid 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/epinephrine avoid combo or use alternative: combo may incr. risk of methemoglobinemia, other adverse effects (additive effects; duplicate tx) [local anesthetics/epinephrine: articaine/epinephrine] nitrates avoid 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] nitrofurantoin avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects)

nitroprusside avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) opiate/acetaminophen combos avoid 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] phenobarbital avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) phenobarbital/hyoscyamine/atropine/scopolamine avoid combo or use alternative: combo w/ phenobarbital may incr. risk of methemoglobinemia (additive effects) phenytoins avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) [phenytoins: fosphenytoin, phenytoin] primaquine avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) sodium oxybate avoid combo: combo may incr. risk of CNS and resp. depression, other adverse effects (additive effects) sulfadiazine avoid combo or use alternative: combo w/ sulfonamides may incr. risk of methemoglobinemia (additive effects) sulfasalazine avoid combo or use alternative: combo w/ sulfonamides may incr. risk of methemoglobinemia (additive effects) trimethoprim/sulfamethoxazole avoid combo or use alternative: combo w/ sulfonamides may incr. risk of methemoglobinemia (additive effects)

Monitor/Modify Tx

azole antifungals monitor 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] boceprevir monitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited)

chloramphenicol monitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited) ciprofloxacin monitor levels w/ systemic lidocaine: combo may incr. lidocaine levels, risk of adverse effects (hepatic metab. inhibited) clarithromycins monitor 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] cobicistat monitor 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] conivaptan monitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited) cyclosporine monitor 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] delavirdine monitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited) erythromycin base monitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited) erythromycin ethylsuccinate monitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited) erythromycin lactobionate monitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited) erythromycin stearate monitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited) fluvoxamine monitor levels w/ systemic lidocaine: combo may incr. lidocaine levels, risk of adverse effects (hepatic metab. inhibited) HIV protease inhibitors monitor 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]

imatinib monitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited) nevirapine monitor levels: combo may decr. lidocaine levels, efficacy (hepatic metab. induced) propranolol monitor levels w/ systemic lidocaine: combo may incr. lidocaine levels, risk of adverse effects (clearance decreased) propranolol/hydrochlorothiazide monitor levels w/ systemic lidocaine: combo may incr. lidocaine levels, risk of adverse effects (clearance decreased) sevelamer give antiarrhythmic 1h before or 3h after, monitor efficacy: combo may decr. antiarrhythmic level, efficacy (absorption possibly decreased) telaprevir monitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited) telithromycin monitor levels w/ systemic lidocaine: combo may incr. lidocaine or active metabolite levels, risk of adverse effects (hepatic metab. inhibited) TNF blocking agents monitor 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] tocilizumab monitor 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) ustekinumab monitor levels: combo may decr. lidocaine levels, efficacy (hepatic metab. possibly altered; ustekinumab may normalize hepatic enzyme formation suppressed by incr. cytokine levels)

Caution Advised

belatacept caution advised: combo may decr. lidocaine levels, efficacy (hepatic metab. possibly altered; belatacept may normalize hepatic enzyme formation suppressed by incr. cytokine levels) chlorpheniramine/hydrocodone caution advised: combo may incr. hydrocodone analgesic effects, incr. respiratory depression, other side effects (additive/synergistic effects)

cimetidine caution advised w/ systemic lidocaine: combo may incr. lidocaine levels, risk of adverse effects (mechanism unknown, hepatic metab. possibly inhibited) clonidine caution 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 combos caution 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 oronasolaryngeal caution 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) epinephrine caution 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) flecainide caution advised: combo may incr. risk of cardiac arrhythmias (additive effects) hydrocodone/chlorpheniramine/pseudoephedrine caution advised: combo may incr. risk of CNS and resp. depression, profound sedation, hypotension, other adverse effects (additive effects) hydrocodone/ibuprofen caution advised: combo may incr. risk of resp. depression, other adverse effects (additive effects) hydrocodone/pseudoephedrine caution advised, consider lower hydrocodone doses: combo may incr. risk of CNS and resp. depression, profound sedation, hypotension, other adverse effects (additive effects) inhaled anesthetics caution advised: combo may incr. risk of cardiac arrhythmias (additive effects) [inhaled anesthetics: desflurane, enflurane, isoflurane, sevoflurane] lidocaine intradermal system caution 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) methadone caution 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 thiosulfate caution 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/antagonists caution 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 combos caution advised: combo may incr. opioid analgesic effects, incr. respiratory depression, other side effects (additive effects) [opiate/aspirin combos: carisoprodol/aspirin/codeine, oxycodone/aspirin] opiates caution 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/ibuprofen caution advised: combo may incr. risk of resp. depression, other adverse effects (additive effects) promethazine/codeine caution 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) propafenone caution advised, if possible withhold antiarrhythmics for 2-3 half-lives before initiating new antiarrhythmic: combo may incr. risk of CNS adverse effects (additive effects) propoxyphene caution advised: combo may incr. opioid analgesic effects, incr. respiratory depression, other side effects (additive effects) [propoxyphene: propoxyphene hydrochloride, propoxyphene napsylate] propoxyphene/acetaminophen caution advised: combo may incr. propoxyphene analgesic effects, incr. respiratory depression, other side effects (additive/synergistic effects) [propoxyphene/acetaminophen: propoxyphene hydrochloride/acetaminophen, propoxyphene napsylate/acetaminophen] sotalol caution 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]

succinylcholine caution advised: combo may potentiate, prolong neuromuscular blockade (mechanism unknown) topical anesthetics caution 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 Action inhibits 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

alprazolam
generic

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

boceprevir contraindicated for oral benzodiazepines, consider decr. parenteral midazolam dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) chloramphenicol contraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) clarithromycins contraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) [clarithromycins: clarithromycin, lansoprazole/amoxicillin/clarithromycin, omeprazole/clarithromycin/amoxicillin] cobicistat contraindicated 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] conivaptan contraindicated during and x7 days after conivaptan tx: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

cyclosporine contraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) [cyclosporine: cyclosporine modified, cyclosporine non-modified] delavirdine contraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) efavirenz contraindicated: combo may alter benzodiazepine levels, incr. risk of CNS depression, psychomotor impairment (hepatic metab. altered, additive effects) efavirenz/emtricitabine/tenofovir disoproxil contraindicated: combo w/ efavirenz may alter benzodiazepine levels, incr. risk of CNS depression, other adverse effects (hepatic metab. altered, additive effects) fluvoxamine contraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) HIV protease inhibitors contraindicated: 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] imatinib contraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) isoniazid contraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) itraconazole contraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) ketoconazole contraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) mifepristone contraindicated 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) posaconazole contraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) sodium oxybate contraindicated: combo may incr. risk of CNS and resp. depression, other adverse effects (additive effects) telaprevir contraindicated for oral benzodiazepines, consider decr. parenteral midazolam dose: combo

may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) telithromycin contraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) voriconazole contraindicated: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

Avoid/Use Alternative

amiodarone use alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) aprepitant use 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, others use 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] ciprofloxacin use alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, other adverse effects (hepatic metab. inhibited) crizotinib avoid combo or use alternative: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) danazol use alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) dronedarone use alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, other adverse effects (hepatic metab. inhibited) erythromycins use 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] fluconazole use alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) grapefruit use 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]

nefazodone use alternative or decr. alprazolam dose 50%: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited; additive effects) pazopanib avoid combo: combo may incr. benzodiazepine levels, risk of CNS depression, other adverse effects (hepatic metab. inhibited) propoxyphene use 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/acetaminophen use 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] rifampin use alternative: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) rifampin/isoniazid use 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/pyrazinamide use 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) tamoxifen use alternative or consider lower benzodiazepine dose: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

Monitor/Modify Tx

aripiprazole caution advised, monitor BP and sedation if parenteral forms used together: combo may incr. risk of CNS depression, psychomotor impairment, orthostatic hypotension (additive effects) dexmedetomidine caution advised, consider dose reduction: combo may incr. risk of CNS depression, other adverse effects (additive effects) propofol caution 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

flumazenil use for therapeutic advantage: combo will reverse sedation, other benzodiazepine effects (antagonistic effects)

Caution Advised

acetaminophen/caffeine/CNS depressant combos caution 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/chlorpheniramine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) acetaminophen/chlorpheniramine/dextromethorphan caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) acetaminophen/chlorpheniramine/dextromethorphan/phenylephrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) acetaminophen/chlorpheniramine/phenylephrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) acetaminophen/diphenhydramine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) acetaminophen/diphenhydramine/dextromethorphan caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) acetaminophen/diphenhydramine/phenylephrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) acetaminophen/doxylamine/dextromethorphan caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) acetaminophen/doxylamine/dextromethorphan/phenylephrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) acetaminophen/doxylamine/dextromethorphan/pseudoephedrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) acetaminophen/doxylamine/phenylephrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects)

acetaminophen/pheniramine/phenylephrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) aldesleukin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) antihistamine/decongestant combos caution 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, sedating caution 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] apomorphine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) artemether/lumefantrine caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) asenapine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) aspirin/chlorpheniramine/dextromethorphan caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) aspirin/chlorpheniramine/dextromethorphan/phenylephrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) aspirin/chlorpheniramine/phenylephrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) aspirin/diphenhydramine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) aspirin/doxylamine/dextromethorphan/phenylephrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) azelastine nasal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal] barbiturates caution 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] belatacept caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. possibly altered; belatacept may normalize hepatic enzyme formation suppressed by incr. cytokine levels) benzodiazepines, all caution 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] bexarotene caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) bosentan caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) brompheniramine/dextromethorphan/phenylephrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) brompheniramine/dextromethorphan/pseudoephedrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) butalbital/acetaminophen caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) calendula caution 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] cannabinoids caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [cannabinoids: dronabinol, nabilone] capsicum caution 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] carbamazepine caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) carisoprodol/aspirin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

cat's claw caution 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 agonists caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [central alpha 2 agonists: clonidine, clonidine transdermal, guanabenz, guanfacine, methyldopa] cetirizine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) cetirizine/pseudoephedrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) chamomile, German caution 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/dextromethorphan caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) chlorpheniramine/dextromethorphan/pseudoephedrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) chlorpheniramine/hydrocodone caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) cimetidine caution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) clozapine caution 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 combos caution 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 combo caution 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 combo caution 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] dantrolene caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) dasatinib caution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) deferasirox caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) dexamethasone caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) [dexamethasone: dexamethasone, dexamethasone sodium phosphate] doxylamine/dextromethorphan caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) droperidol caution advised: combo may incr. risk of CNS depression, QT prolongation and arrhythmias (additive effects, mechanism unknown) enzalutamide caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) ethanol caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) ethosuximide caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) etomidate caution advised: combo may incr. risk of CNS and resp. depression, psychomotor impairment (additive effects) etravirine caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) ezogabine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) fluoxetine caution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

gabapentin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [gabapentin: gabapentin, gabapentin enacarbil] ginseng, Siberian caution 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] goldenseal caution 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 kola caution 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 tea caution 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] griseofulvins caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) [griseofulvins: griseofulvin microsize, griseofulvin ultramicrosize] guarana caution 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] haloperidol caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [haloperidol: haloperidol, haloperidol decanoate, haloperidol lactate] hawthorn caution 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/pseudoephedrine caution advised: combo may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive effects) hydrocodone/ibuprofen caution 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/pseudoephedrine caution advised: combo may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive effects) iloperidone caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) inhaled anesthetics caution advised: combo may incr. risk of CNS and resp. depression, psychomotor impairment (additive effects) [inhaled anesthetics: desflurane, enflurane, isoflurane, sevoflurane] kava caution 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] ketamine caution advised: combo may incr. risk of CNS and resp. depression, psychomotor impairment (additive effects) lanreotide caution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) lapatinib caution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) lemon balm caution 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] levocetirizine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) licorice caution 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] loxapine caution advised: combo may incr. risk of CNS depression, psychomotor impairment; hypotension/respiratory depression/stupor reported w/ loxapine and lorazepam (additive effects) lurasidone caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

maprotiline caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) meprobamate caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) methadone caution 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) metoclopramide caution advised: combo may incr. risk of CNS depression (additive effects) mirtazapine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) mitotane caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) modafinil caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) [modafinil: armodafinil, modafinil] morphine liposomal caution advised: combo may incr. risk of CNS and resp. depression, profound sedation, hypotension, other adverse effects (additive effects) muscle relaxants caution 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/esomeprazole caution advised w/ alprazolam ODT form: combo w/ esomeprazole may decr. alprazolam levels, delay effects (disintegration/dissolution, absorption slowed or decreased if gastric pH elevated) nevirapine caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) nilotinib caution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited) NSAID/chlorpheniramine/pseudoephedrine combos caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) [NSAID/chlorpheniramine/pseudoephedrine combos: ibuprofen/chlorpheniramine/pseudoephedrine] NSAID/diphenhydramine combos caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of

CNS depression (additive effects) [NSAID/diphenhydramine combos: ibuprofen/diphenhydramine] octreotide caution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. possibly inhibited) olanzapine caution advised: combo may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive effects) olanzapine/fluoxetine caution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited; additive effects) olopatadine nasal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) opiate agonist/antagonists caution 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 combos caution 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 combos caution advised: combo may incr. risk of CNS and resp. depression, psychomotor impairment (additive effects) [opiate/aspirin combos: carisoprodol/aspirin/codeine, oxycodone/aspirin] opiates caution 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] oxcarbazepine caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) oxycodone/ibuprofen caution 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) paliperidone caution advised: combo may incr. risk of CNS depression, psychomotor impairment

(additive effects) [paliperidone: paliperidone, paliperidone palmitate] passionflower caution 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/phenylephrine caution advised: combo of benzodiazepines and sedating antihistamines may incr. risk of CNS depression (additive effects) phenobarbital/hyoscyamine/atropine/scopolamine caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) phenothiazines caution 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] phenytoins caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) [phenytoins: fosphenytoin, phenytoin] pimozide caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) pramipexole caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) pregabalin caution advised: combo may incr. risk of CNS depression, psychomotor impairment, adverse effects (additive effects) promethazine/codeine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) quetiapine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) quinine sulfate caution advised: combo may incr. benzodiazepine levels, risk of CNS depression, other adverse effects (hepatic metab. inhibited) quinupristin/dalfopristin caution advised: combo may incr. benzodiazepine levels, risk of CNS depression, psychomotor impairment (hepatic metab. inhibited)

ranolazine caution advised: combo may incr. benzodiazepine levels, risk of CNS depression, other adverse effects (hepatic metab. inhibited) red clover caution 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] rifabutin caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) rifapentine caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) risperidone caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) ropinirole caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) rotigotine transdermal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) rufinamide caution advised: combo may decr. benzodiazepine levels, efficacy; may incr. risk of CNS depression, psychomotor impairment (hepatic metab. induced; additive effects) sedative/hypnotics caution 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 wort caution 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] tapentadol caution advised, consider lower doses: combo may incr. risk of CNS and resp. depression, psychomotor impairment (additive effects) tetrabenazine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) thalidomide caution advised: combo may incr. risk of CNS depression (additive effects) thiothixene caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

tiagabine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) TNF blocking agents caution 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] tocilizumab caution 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) topiramate caution 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] tramadol caution advised, consider lower tramadol dose: combo may incr. risk of CNS and resp. depression, psychomotor impairment (additive effects) tramadol/acetaminophen caution advised: combo w/ tramadol may incr. risk of CNS and respiratory depression, psychomotor impairment (additive effects) trazodone caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) tricyclic antidepressants caution 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] ustekinumab caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. possibly altered; ustekinumab may normalize hepatic enzyme formation suppressed by incr. cytokine levels) valerian caution 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 derivatives caution advised: combo may incr. risk of CNS depression, psychomotor impairment

(additive effects) [valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid] vemurafenib caution advised: combo may decr. benzodiazepine levels, efficacy (hepatic metab. induced) vigabatrin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) ziconotide intrathecal caution advised: combo may incr. risk of confusion, dizziness, other CNS adverse effects (additive effects) [ziconotide intrathecal: ziconotide] ziprasidone caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) zonisamide caution 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 Action binds 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 Genrico: alprazolam Nombres de las Marcas: Niravam, Xanax, Xanax XR

Cul es la informacin ms importante que debo saber sobre alprazolam?

No use alprazolam si usted est embarazada. Le puede causar dao al beb nonato.

No use esta medicina si tiene alergia a alprazolam o a otro benzodiazepnico, como chlordiazepoxide (Librium), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), o oxazepam (Serax). Antes de tomar alprazolam, dgale a su mdico si usted tiene algn problema con la respiracin, glaucoma, enfermedad del rin o del hgado, o historial de depresin, pensamientos de querer suicidarse, o adiccin a drogas o al alcohol.

No beba alcohol mientras est 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.

Qu es alprazolam?
Alprazolam es un benzodiazepnico. Alprazolam afecta los qumicos 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 pnico, y la ansiedad causada por la depresin. Alprazolam puede tambin usarse para fines no mencionados en esta gua del medicamento.

Qu debera discutir con el profesional de la salud antes de tomar alprazolam?

Es peligroso comprar alprazolam por el Internet o a travs de vendedores situados fuera de los Estados Unidos de Norteamrica. 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 antipsictica que tiene efectos secundarios graves. Para ms informacin, comunquese 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 ngulo estrecho; si tambin est tomando itraconazole (Sporanox) o ketoconazole (Nizoral); o tiene alergia a alprazolam o a otro benzodiazepnico, como chlordiazepoxide (Librium), clorazepate (Tranxene), diazepam (Valium), lorazepam (Ativan), o oxazepam (Serax).

Para asegurarse que usted puede tomar alprazolam de forma segura, dgale a su mdico si usted tiene cualquiera de estas otras condiciones:

asma, enfisema, bronquitis, enfermedad pulmonar obstructiva crnica (EPOC; COPD por sus siglas in ingls), u otro problema con la respiracin; glaucoma; enfermedad del rin o del hgado (en particular enfermedad del hgado por alcoholismo); historial de depresin o pensamientos de querer suicidarse o tomar acciones para tal fin; o historial de adiccin a la droga o al alcohol.

Alprazolam puede crear hbito y debera ser usado solamente para la persona a quien se le recet. Nunca comparta alprazolam con otra persona, especialmente con alguien con historial de abuso de drogas o adiccin. Mantenga el medicamento en un lugar donde otros no lo puedan encontrar.

Categora D del embarazo por la FDA. No use alprazolam si usted est embarazada. Le puede causar dao al beb nonato. Alprazolam puede tambin causar adiccin o sntomas de abstinencia en un recin nacido si la madre toma el medicamento durante el embarazo. Use un mtodo efectivo de control de la natalidad, y dgale a su mdico si usted queda embarazada durante el tratamiento.

Alprazolam puede pasar a la leche materna y causarle dao al beb lactante. Usted no debe amamantar mientras est usando alprazolam. Los efectos sedativos de alprazolam pueden durar ms tiempo en los adultos de edad avanzada. Cadas accidentales ocurren comnmente en los ancianos que toman benzodiazepnicos. Tome medidas de precaucin para evitar caerse o herirse accidentalmente mientras est tomando alprazolam.

No le d esta medicina a nadie menor de los 18 aos.

Cmo debo tomar alprazolam?

Tmelo exactamente como lo haya recetado su mdico. No lo tome en cantidades mayores o menores, o por ms tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripcin. Tal vez su mdico en ocasiones cambie su dosis para asegurarse de que est obteniendo los mejores resultados.

No triture, mastique, o rompa una tableta de liberacin prolongada. Trague la pastilla entera. sta ha sido preparada de forma especial para liberar la medicina lentamente al cuerpo. Si la rompe, causara que salga la medicina junta. Mida la formulacin lquida 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, pdale una a su farmacutico. No se trague entera la tableta oral que se desintegra. Deje que se disuelva en la boca sin tener que masticar.

Hable con su mdico si le parece que esta medicina ha dejado de funcionar para tratar sus sntomas de pnico o ansiedad. Usted puede tener convulsiones o el sndrome de abstinencia cuando pare de usar alprazolam. Pregntele a su mdico cmo evitar los sntomas 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 debera saber si alguien est usando su medicina inapropiadamente o sin prescripcin.

Guarde a temperatura ambiente fuera de la humedad y del calor.

Qu sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome ms medicina para alcanzar la dosis pasada.

Qu sucedera en una sobredosis?

Busque atencin mdica de emergencia o llame a la lnea de Poison Help al 1-800-222-1222. La sobredosis de alprazolam podra ser fatal. Los sntomas pueden incluir somnolencia extrema, confusin, debilidad musculares, perdida de balance o coordinacin, sensacin de desvanecimiento, y desmayo.

Qu debo evitar mientras tomo alprazolam?

No beba alcohol mientras est tomando alprazolam. Esta medicina puede aumentar los efectos del alcohol.

Alprazolam puede perjudicar su pensamiento o reacciones. Tenga cuidado si usted conduce un vehculo 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 mdico acerca del uso de productos de toronja.

Cules son los efectos secundarios posibles de alprazolam?

Busque atencin mdica de emergencia si nota alguno de estos sntomas de una reaccin alrgica: ronchas; dificultad para respirar; hinchazn de la cara, labios, lengua, o garganta.

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

depresin, piensa en suicidarse o hacerse dao, inusual comportamiento de alto riesgo, disminucin de las inhibiciones, perder el miedo al peligro; confusin, hiperactividad, agitacin, hostilidad, alucinaciones; sentir que se puede desmayar; orinar menos de lo usual o nada en absoluto; dolor de pecho, latidos cardacos fuertes o aleteo cardaco 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; visin borrosa, dolor de cabeza, problemas de la memoria, dificultad para concentrarse; problemas para dormir (insomnio); hinchazn en sus manos o pies; debilidad muscular, falta de balance o coordinacin, habla arrastrado; malestar estomacal, nusea, vmito, estreimiento, diarrea; aumento del sudor, boca seca, nariz tupida; o cambios en el apetito o el peso, prdida de inters en la actividad sexual.

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

Qu otras drogas afectarn a alprazolam?

Antes de usar alprazolam, dgale a su mdico si usted usa con regularidad otras drogas que causan somnolencia (como medicinas para el resfriado o alergias, otras sedantes, narcticos para el control del dolor, pastillas para dormir, relajantes musculares, y medicinas para las convulsiones, depresin, o ansiedad). Estas pueden aadir a la somnolencia que causa alprazolam. Dgale a su mdico 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 antibitico como clarithromycin (Biaxin), erythromycin (E.E.S., EryPed, Ery-Tab, Erythrocin, Pediazole), rifabutin (Mycobutin), rifampin (Rifadin, Rifater, Rifamate), rifapentine (Priftin), o telithromycin (Ketek); medicamento antifngico como miconazole (Oravig) o voriconazole (Vfend); un antidepresivo como fluoxetine (Prozac, Sarafem, Symbyax), fluvoxamine (Luvox), desipramine (Norpramin), imipramine (Janimine, Tofranil), o nefazodone; un barbitrico como butabarbital (Butisol), secobarbital (Seconal), pentobarbital (Nembutal), o phenobarbital (Solfoton); medicamento para el corazn o la presin 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. Dgale a su mdico 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 mdico.

Dnde puedo obtener ms informacin?

Su farmacutico le puede dar ms informacin sobre alprazolam (Xanax).

Drug

clopidogrel
generic

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/aspirin weigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects) acetaminophen/aspirin/caffeine weigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects) antiplatelets weigh risk/benefit: combo may incr. risk of bleeding (additive effects) [antiplatelets: anagrelide, cilostazol, clopidogrel, dipyridamole, prasugrel, ticagrelor, ticlopidine] aspirin weigh risk/benefit, low dose ASA OK: combo may incr. risk of bleeding (additive effects) aspirin/caffeine weigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects) aspirin/calcium carbonate weigh risk/benefit, low dose ASA OK: combo may incr. risk of bleeding (additive effects) aspirin/chlorpheniramine/dextromethorphan weigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects) aspirin/chlorpheniramine/dextromethorphan/phenylephrine weigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects) aspirin/chlorpheniramine/phenylephrine weigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects) aspirin/diphenhydramine weigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects)

aspirin/dipyridamole weigh risk/benefit: combo may incr. risk of bleeding (additive effects) aspirin/doxylamine/dextromethorphan/phenylephrine weigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects) aspirin/phenylephrine weigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects) carisoprodol avoid combo: combo may incr. carisoprodol levels, risk of adverse effects (hepatic metab. inhibited) carisoprodol/aspirin avoid 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/codeine avoid 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) chloramphenicol avoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite) cimetidine avoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite) CNS depressant/aspirin/caffeine combos weigh 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] danshen avoid 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] delavirdine avoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite) drotrecogin alfa weigh risk/benefit if antiplatelets w/in 7 days prior to drotrecogin alfa: combo may incr. risk of bleeding (additive effects) efavirenz avoid 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 disoproxil avoid 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) esomeprazole avoid 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) etravirine avoid 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) felbamate avoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite) fluconazole avoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite) fluoxetine avoid 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) fluvoxamine avoid 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) fondaparinux weigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects) heparins weigh risk/benefit: combo may incr. risk of bleeding (additive effects) [heparins: dalteparin, enoxaparin, heparin, tinzaparin] ibritumomab tiuxetan weigh risk/benefit, monitor platelets: combo may incr. risk of bleeding (additive effects, ibritumomab induces severe prolonged thrombocytopenia) isoniazid avoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite) ketoconazole avoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite) modafinil avoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite) [modafinil: armodafinil, modafinil] naproxen/esomeprazole avoid 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/fluoxetine avoid 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) omeprazole avoid 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/amoxicillin avoid 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) oseltamivir use alternative: combo may decr. oseltamivir efficacy (hepatic metab. inhibited, decr. conversion to active oseltamivir metabolite) oxcarbazepine avoid combo: combo may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite) oxycodone/aspirin weigh risk/benefit: combo w/ aspirin may incr. risk of bleeding (additive effects) pentosan polysulfate sodium weigh risk/benefit: combo may incr. risk of bleeding (additive effects) platelet GP IIb/IIIa inhibitors weigh risk/benefit: combo may incr. risk of bleeding (additive antiplatelet effects) [platelet GP IIb/IIIa inhibitors: abciximab, eptifibatide, tirofiban] rifampin/isoniazid avoid combo: combo w/ isoniazid may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite) rifampin/isoniazid/pyrazinamide avoid combo: combo w/ isoniazid may decr. clopidogrel efficacy (hepatic metab. inhibited, possibly decr. conversion of clopidogrel to active metabolite) rivaroxaban weigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects) thrombolytics weigh risk/benefit: combo may incr. risk of bleeding (additive effects) [thrombolytics: alteplase, reteplase, tenecteplase] tipranavir avoid 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) voriconazole avoid 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) warfarin weigh risk/benefit: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects)

Monitor/Modify Tx

bupropion caution 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, German caution 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] citalopram max 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) phenytoins caution advised, monitor phenytoin levels: may incr. phenytoin levels, risk of toxicity (hepatic metab. inhibited) [phenytoins: fosphenytoin, phenytoin] pioglitazone/glimepiride monitor glucose: combo may incr. sulfonylurea levels, risk of hypoglycemia (hepatic metab. inhibited) red clover caution 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] tolbutamide monitor glucose: combo may incr. tolbutamide levels, risk of hypoglycemia, other adverse effects (hepatic metab. inhibited)

Caution Advised

atovaquone/proguanil caution advised: combo may decr. proguanil active metabolite levels, efficacy (hepatic metab. inhibited, decr. conversion to active metabolite) bivalirudin caution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects) bosentan caution advised unless combined w/ moderate or strong CYP3A4 inhibitor, then avoid combo: combo may incr. bosentan levels, risk of toxicity (hepatic metab. inhibited) capsicum caution 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] clomipramine caution advised: combo may incr. clomipramine levels, risk of adverse effects (hepatic metab. inhibited) collagenase clostridium histolyticum caution advised: combo may incr. risk of bleeding (additive effects) cyclophosphamide caution advised: combo may decr. cyclophosphamide active metabolite levels, efficacy (hepatic metab. inhibited, decr. conversion to active metabolite) darunavir caution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects) dasatinib caution advised: combo may incr. risk of bleeding (additive antiplatelet effects) deferasirox caution advised: combo may incr. risk of GI bleeding (additive effects) desipramine caution advised: combo may incr. desipramine levels, risk of adverse effects (hepatic metab. inhibited) desirudin caution advised: combo may incr. risk of bleeding (additive effects) desvenlafaxine caution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake) diazepam caution advised: combo may incr. diazepam levels, risk of adverse effects (hepatic metab. inhibited) [diazepam: diazepam, diazepam rectal] diclofenac topical caution 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 quai caution 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] doxepin caution advised: combo may incr. doxepin levels, risk of adverse effects (hepatic metab. inhibited) duloxetine caution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake) escitalopram caution 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 oil caution 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] fenugreek caution 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 foenumgraecum] feverfew caution 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] flaxseed caution 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] fluvastatin caution advised: combo may incr. fluvastatin levels, risk of myopathy, rhabdomyolysis (hepatic metab. inhibited) garlic caution 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] ginger caution 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 biloba caution 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, Asian caution 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, Siberian caution 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 tea caution 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 seed caution 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/ibuprofen caution advised: combo may incr. risk of bleeding (additive effects) ibuprofen/famotidine caution advised: combo w/ ibuprofen may incr. risk of bleeding (additive effects) ifosfamide caution 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 inhaled caution advised: combo may incr. risk of bleeding (additive antiplatelet effects) imipramine caution advised: combo may incr. imipramine levels, risk of adverse effects (hepatic metab. inhibited) ketamine caution advised: combo may incr. ketamine levels, risk of CNS and resp. depression, other adverse effects (hepatic metab. inhibited) meperidine caution advised: combo may incr. meperidine levels, risk of respiratory depression, other adverse effects (hepatic metab. inhibited)

methadone caution advised: combo may incr. methadone levels, incr. risk of QT prolongation, cardiac arrhythmias, other adverse effects (hepatic metab. inhibited) milnacipran caution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake) nevirapine caution advised: combo may incr. nevirapine levels, risk of adverse effects (hepatic metab. inhibited) NSAID/chlorpheniramine/pseudoephedrine combos caution advised: combo w/ NSAIDs may incr. risk of bleeding (additive effects) [NSAID/chlorpheniramine/pseudoephedrine combos: ibuprofen/chlorpheniramine/pseudoephedrine] NSAID/diphenhydramine combos caution advised: combo w/ NSAIDs may incr. risk of bleeding (additive effects) [NSAID/diphenhydramine combos: ibuprofen/diphenhydramine] NSAID/phenylephrine combos caution advised: combo w/ NSAIDs may incr. risk of bleeding (additive effects) [NSAID/phenylephrine combos: ibuprofen/phenylephrine] NSAID/pseudoephedrine combos caution advised: combo w/ NSAIDs may incr. risk of bleeding (additive effects) [NSAID/pseudoephedrine combos: ibuprofen/pseudoephedrine, naproxen sodium/pseudoephedrine] NSAIDs caution 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, ophthalmic caution advised: combo may incr. ocular bleeding risk postop (additive effects) [NSAIDs, ophthalmic: bromfenac ophthalmic, diclofenac ophthalmic, flurbiprofen ophthalmic, ketorolac ophthalmic, nepafenac ophthalmic] olanzapine caution advised: combo may incr. olanzapine levels, risk of adverse effects (hepatic metab. inhibited) omega-3-acid caution advised: combo may incr. risk of bleeding (additive antiplatelet effects) [omega-3-acid: omega-3-acid ethyl esters] oxycodone/ibuprofen caution advised: combo may incr. risk of bleeding (additive effects) paroxetine caution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake)

pentamidine caution advised: combo may incr. pentamidine levels, risk of adverse effects, incl. QT prolongation, cardiac arrhythmias (hepatic metab. inhibited) porfimer caution advised: combo may decr. efficacy of photodynamic tx; antiplatelet agents may decr. thromboxane A2-mediated tumor necrosis (antagonistic effects) propofol caution advised: combo may incr. propofol levels, risk CNS and respiratory depression, other adverse effects (hepatic metab. inhibited) [propofol: fospropofol, propofol] propranolol caution advised: combo may incr. propranolol levels, risk of adverse effects (hepatic metab. inhibited) selegiline caution advised: combo may incr. selegiline levels, risk of adverse effects (hepatic metab. inhibited) selegiline transdermal caution advised: combo may incr. selegiline levels, risk of adverse effects (hepatic metab. inhibited) sertraline caution 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) sibutramine caution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake) sumatriptan/naproxen sodium caution advised: combo w/ NSAIDs may incr. risk of bleeding (additive effects) thrombin inhibitors caution advised: combo may incr. risk of bleeding (additive anticoagulant/antiplatelet effects) [thrombin inhibitors: antithrombin (recombinant), antithrombin III, argatroban, dabigatran, lepirudin] tramadol caution advised: combo may incr. tramadol levels, risk of seizures, other adverse effects (hepatic metab. inhibited) tramadol/acetaminophen caution advised: combo may incr. tramadol levels, risk of seizures, other adverse effects (hepatic metab. inhibited) trazodone caution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake) treprostinil caution advised: combo may incr. risk of bleeding (additive antiplatelet effects) [treprostinil: treprostinil, treprostinil inhaled]

valproic acid derivatives caution advised: combo may incr. risk of bleeding (additive antiplatelet effects) [valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid] vardenafil caution advised: combo may incr. vardenafil levels, risk of adverse effects (hepatic metab. inhibited) venlafaxine caution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake) verteporfin caution advised: combo may decr. verteporfin efficacy (mechanism unknown) vilazodone caution advised: combo may incr. risk of bleeding (synergistic effects, antiplatelet effects augmented by inhibition of platelet serotonin uptake) willow bark caution 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 Action irreversibly 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 Genrico: clopidogrel Nombre de la Marca: Plavix

Cul es la informacin ms importante que debo saber sobre clopidogrel?

Clopidogrel hace que su sangre no forme cogulos para evitar los indeseados cogulos de la sangre que pueden ocurrir con ciertas condiciones del corazn o de los vasos sanguneos. A consecuencia de esta accin de la droga, clopidogrel puede hacer fcil a que sangre, aun cuando el corte es mnimo. Hable con su mdico o busque atencin medica de emergencia si tiene sangramiento que no lo puede parar.

Usted tambin puede tener sangramiento dentro del cuerpo, as como en su estmago o intestinos. Hable de inmediato con su mdico si tiene heces fecales negras o con sangre, o si la tos tiene sangre o el vmito tiene la apariencia de caf molido. Estos pueden ser sntomas de sangramiento en su tracto digestivo.

Evite beber alcohol. Le puede aumentar su riesgo de sangramiento en su estmago o intestinos.

Si necesite ciruga o procedimiento dental, informe a los cirujanos o dentistas en adelantado que usted est usando clopidogrel. Tal vez necesite dejar de usar la medicina por lo menos 5 das antes de tener una ciruga para evitar sangrar en exceso. Siga las instrucciones de su mdico y empiece a tomar clopidogrel otra vez tan pronto sea posible.

Mientras est tomando clopidogrel, no tome aspirin u otro AINE (anti-inflamatorio no esteroide (NSAIDs, por sus siglas en Ingls)) sin la aprobacin de su mdico. Los AINEs (NSAIDs) incluyen ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn, Naprelan, Treximet), celecoxib (Celebrex), diclofenac (Cataflam, Voltaren), indomethacin (Indocin), meloxicam (Mobic), y otras. Dgale a su mdico acerca de todas las medicinas que usted use para prevenir los cogulos sanguneos.

Qu es clopidogrel?
Clopidogrel previene la acumulacin (formacin de cogulo) de las plaquetas en la sangre. Esto evita que se formen cogulos sanguneos que pueden ocurrir con ciertas condiciones cardiacas o de los vasos sanguneos.. Clopidogrel se usa en la prevencin de cogulos sanguneos despus de un reciente ataque cardiaco o accidente cerebrovascular, y en las personas con problemas del corazn o de los vasos sanguneos. Clopidogrel puede usarse tambin para fines distintos a los que se sealan en esta gua del medicamento.

Qu debera 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 lcera del estmago o sangramiento en el cerebro (de una herida a la cabeza).

Si usted tiene cualquiera de estas otras condiciones, usted quizs necesite modificar su dosis o pruebas especiales:

problema de sangramiento o de cogulos de sangre, como TTP (prpura trombocitopnica trombtica) o hemofilia; historia de accidente cerebrovascular, que incluye TIA ("mini-stroke"); lcera del estmago o colitis ulcerativa; o enfermedad del rin.

Clasificado por la FDA en la categora B de Riesgos a la Gestacin. No se anticipa que esta medicina le haga dao al beb nonato. Dgale a su mdico si usted est embarazada o planea un embarazo durante su tratamiento.

No se sabe si clopidogrel pasa a la leche materna o si le puede hacer dao al beb que est mamando. No use esta medicina sin consultar antes con su mdico si est dando de amamantar al beb.

Cmo debo tomar clopidogrel?

Tmelo exactamente cmo lo haya recetado su mdico. No lo tome en cantidades mayores o menores, o por ms tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripcin.

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 coagul (cogulos) para evitar cogulos de sangre no deseados, puede tambin hacer ms fcil a que sangre, aun cuando la herida es pequea. Hable con su mdico o busque atencin medica de emergencia si tiene sangramiento que no lo puede parar.

Si necesite ciruga o procedimiento dental, informe a los cirujanos o dentistas en adelantado que usted est usando clopidogrel. Tal vez necesite dejar de usar la medicina por lo menos 5 das antes de tener una ciruga para evitar sangrar en exceso. Siga las instrucciones de su mdico y empiece a tomar clopidogrel otra vez tan pronto sea posible.

No deje de usar clopidogrel sin primero hablar con su mdico. Usar clopidogrel regularmente para obtener el mayor beneficio. Vuelva a llenar su prescripcin antes de que se quede completamente sin medicina.

Para estar seguro de que esta medicina no le est haciendo dao, se necesitar examinar su sangre con frecuencia. Visite a su mdico con regularidad.

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

Qu sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome ms medicina para alcanzar la dosis pasada.

Qu sucedera en una sobredosis?

Busque atencin mdica de emergencia o llame a la lnea de Poison Help al 1-800-222-1222. Los sntomas de una sobredosis de clopidogrel pueden incluir vmito, sentirse muy cansado o que le falta aire al respirar y sangre en sus heces fecales o vmito.

Qu debo evitar mientras tomo clopidogrel?

Mientras est tomando clopidogrel, no tome aspirin u otro AINE (anti-inflamatorio no esteroide (NSAIDs, por sus siglas en Ingles)) sin la aprobacin de su mdico. 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 estmago o intestinos.

Cules son los efectos secundarios posibles de clopidogrel?

Busque atencin mdica de emergencia si tiene alguno de estos sntomas de una reaccin alrgica: ronchas, dificultad para respirar, hinchazn de la cara, labios, lengua, o garganta.

Deje de usar clopidogrel y hable de inmediato con su mdico 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 vmito con apariencia a caf molido; dolor del pecho o sensacin de peso, dolor que se reparte al brazo u hombro, nusea, sudor, sentirse enfermo; entumecimiento sbito o debilidad, en particular a un lado del cuerpo; dolor sbito de la cabeza, confusin, problemas con la visin, el hablar, o el balance; piel plida, debilidad, fiebre, o ictericia (color amarillo de la piel u ojos); o moretones fcil, 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 picazn. Esta lista no menciona todos los efectos secundarios y puede ser que ocurran otros. Llame a su mdico para consejos mdicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

Qu otras drogas afectarn a clopidogrel?

Dgale a su mdico acerca de todas las medicinas que usted use para prevenir los cogulos sanguneos, incluyendo:

abciximab (ReoPro); dalteparin (Fragmin); enoxaparin (Lovenox); eptifibatide (Integrilin); fondaparinux (Arixtra); heparin; ticlopidine (Ticlid); tinzaparin (Innohep); tirofiban (Aggrastat); urokinase (Abbokinase); y warfarin (Coumadin, Jantoven).

Dgale a su mdico 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 cncer como dasatinib (Sprycel), letrozole (Femara), ibritumomab (Zevalin), o tositumomab (Bexxar); algunos medicinas que se usan para reducir la cantidad de cido en el estmago, como cimetidine (Tagamet), esomeprazole (Nexium), o omeprazole (Prilosec, Prilosec OTC, Zegerid);

una medicina antifngica 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. Dgale a su mdico 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 mdico.

Dnde puedo obtener ms informacin?

Su farmacutico le puede dar ms informacin sobre clopidogrel (Plavix).

Drug

nitroglycerin

generic

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 5200 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

sildenafil contraindicated: combo may incr. risk of severe hypotension, cardiovascular collapse (synergistic effects) tadalafil contraindicated, allow 48h after last tadalafil dose before giving nitrates: combo may incr. risk of severe hypotension, cardiovascular collapse (synergistic effects) vardenafil contraindicated: combo may incr. risk of severe hypotension, tachycardia, cardiovascular collapse (synergistic effects)

Avoid/Use Alternative

ergot alkaloids avoid 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/caffeine avoid combo: combo may decr. nitrate efficacy; incr. risk of vasoconstriction, angina, ischemia observed w/ DHE (antagonistic effects; DHE metab. altered by NTG) ethanol avoid or minimize alcohol use: combo may incr. risk of hypotension (additive effects) local anesthetics avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) [local anesthetics: bupivacaine, bupivacaine liposomal, chloroprocaine, lidocaine, mepivacaine, procaine, ropivacaine] local anesthetics/epinephrine avoid combo or use alternative: combo may incr. risk of methemoglobinemia (additive effects) [local anesthetics/epinephrine: articaine/epinephrine] promethazine/codeine avoid combo or use alternative: combo w/ phenothiazines may incr. risk of hypotension (additive effects) rosiglitazone avoid combo: combo may incr. risk of myocardial ischemia (mechanism unknown) rosiglitazone/glimepiride avoid combo: combo may incr. risk of myocardial ischemia (mechanism unknown) rosiglitazone/metformin avoid combo: combo may incr. risk of myocardial ischemia (mechanism unknown)

Monitor/Modify Tx

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

amlodipine/ARB combos caution advised, monitor BP: combo may incr. risk of hypotension (additive effects) [amlodipine/ARB combos: amlodipine/olmesartan, amlodipine/valsartan, telmisartan/amlodipine] amlodipine/ARB/thiazide combos caution advised, monitor BP: combo may incr. risk of hypotension (additive effects) [amlodipine/ARB/thiazide combos: amlodipine/valsartan/hydrochlorothiazide, olmesartan/amlodipine/hydrochlorothiazide] asenapine monitor BP: combo may incr. risk of hypotension (additive effects) heparin monitor aPTT: combo, esp. with IV nitroglycerin, may decr. anticoagulant efficacy of heparin (mechanism unknown) iloperidone monitor BP: combo may incr. risk of hypotension (additive effects) isosorbide dinitrate/hydralazine monitor BP: combo may incr. risk of hypotension (additive effects, duplicate nitrate tx) nesiritide monitor BP: combo may incr. risk of hypotension (additive/synergistic effects)

Caution Advised

aldesleukin caution advised: combo may incr. risk of hypotension (additive effects) alfuzosin caution advised: combo may incr. risk of hypotension, syncope (additive effects) aliskiren/amlodipine caution advised: combo may incr. risk of orthostatic hypotension (additive effects) aliskiren/amlodipine/hydrochlorothiazide caution advised: combo may incr. risk of orthostatic hypotension (additive effects) alteplase caution advised w/ IV, SL nitroglycerin: combo w/ IV nitroglycerin may decr. thrombolytic efficacy of alteplase; similar effect possible w/ SL nitroglycerin (mechanism unknown) amlodipine/atorvastatin caution advised: combo may incr. risk of hypotension (additive effects) anticholinergics caution 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] apomorphine caution advised: combo may incr. risk of orthostatic hypotension, MI, pneumonia, falls, other apomorphine adverse effects (additive effects)

benzocaine contraindicated 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 combos contraindicated 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, dihydropyridines caution advised: combo may incr. risk of hypotension (additive effects) [calcium channel blockers, dihydropyridines: amlodipine, amlodipine/benazepril, felodipine, isradipine, nicardipine, nifedipine, nimodipine, nisoldipine] clevidipine caution advised: combo may incr. risk of hypotension (additive effects) darifenacin caution advised w/ SL nitroglycerin: anticholinergics may decr. salivary secretions and dissolution of SL tablets (absorption decreased) diltiazem caution advised: combo may incr. risk of hypotension (additive effects) disopyramide caution advised w/ SL nitroglycerin: disopyramide may decr. salivary secretions and dissolution of SL tablets (absorption decreased) hawthorn caution 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 inhaled caution advised: combo may incr. risk of hypotension (additive/synergistic effects) lidocaine topical contraindicated 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]

maraviroc caution advised: combo may incr. risk of orthostatic hypotension (additive effects) niacin caution advised: combo may incr. risk of orthostatic hypotension (additive effects) niacin/lovastatin caution advised: combo w/ niacin may incr. risk of orthostatic hypotension (additive effects) niacin/simvastatin caution advised: combo w/ niacin may incr. risk of orthostatic hypotension (additive effects) nitrites/sodium thiosulfate caution advised: combo may incr. risk of methemoglobinemia, hypotension (additive effects) [nitrites/sodium thiosulfate: amyl nitrite/sodium nitrite/sodium thiosulfate, sodium nitrite/sodium thiosulfate] nitroprusside caution advised: combo may incr. risk of methemoglobinemia (additive effects) phenobarbital/hyoscyamine/atropine/scopolamine caution advised w/ SL nitroglycerin: anticholinergics may decr. salivary secretions and dissolution of SL tablets (absorption decreased) phenothiazines caution 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] silodosin caution advised: combo may incr. risk of hypotension, syncope (additive effects) solifenacin caution advised w/ SL nitroglycerin: anticholinergics may decr. salivary secretions and dissolution of SL tablets (absorption decreased) treprostinil caution advised: combo may incr. risk of symptomatic hypotension (additive effects) [treprostinil: treprostinil, treprostinil inhaled] tricyclic antidepressants caution 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] verapamils caution 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 drugspecific 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 Action stimulates 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 Genrico: nitroglycerin (oral/sublingual) Nombres de las Marcas: Nitro-Time, Nitrolingual, Nitrolingual Duo Pack, Nitromist, Nitrostat

Cul es la informacin ms importante que debo saber sobre nitroglycerin?

No use nitroglycerin si usted est tomando sildenafil (Viagra, Revatio), tadalafil (Cialis), o vardenafil (Levitra). Efectos secundarios graves, que ponen su vida en peligro, pueden ocurrir si toma nitroglycerin mientras est 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. Pregntele a su mdico antes usar alguna medicina para el dolor de cabeza.

Qu es nitroglycerin?
Nitroglycerin miembro del grupo de drogas denominadas nitratos. Nitroglycerin dilata (ensancha) los vasos sanguneos, haciendo ms fcil para que el flujo de sangre pase a travs de estos y para que el corazn pueda bombear con ms facilidad. Nitroglycerin se usa para el tratamiento o prevencin del ataque de dolor al pecho (angina).

Nitroglycerin puede tambin usarse para fines no mencionados en esta gua del medicamento.

Qu debera discutir con el profesional de la salud antes de tomar nitroglycerin?

No use nitroglycerin si usted est tomando sildenafil (Viagra, Revatio), tadalafil (Cialis), o vardenafil (Levitra). Efectos secundarios graves, que ponen su vida en peligro, pueden ocurrir si toma nitroglycerin mientras est usando sildenafil. No use esta medicina sin el consejo de su mdico si usted tiene sntomas tempranos de un ataque al corazn (dolor del pecho o pesadez en el pecho, dolor que se extiende al brazo u hombro, nusea, sudor, sentirse enfermo). Busque atencin mdica de emergencia si usted tiene sntomas de ataque al corazn.

No use esta medicina si usted es alrgico 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 clulas rojas de la sangre); o una herida en el cerebro, hemorragia, o tumor.

Para asegurarse que usted puede tomar nitroglycerin de forma segura, dgale a su mdico si usted tiene cualquiera de estas otras condiciones:

fallo cardiaco congestivo; historial de ataque al corazn, de accidente cerebrovascular, o herida en la cabeza; presin arterial baja; glaucoma; migraas; o enfermedad del hgado.

Categora C del embarazo por la FDA. No se conoce si nitroglycerin causar dao al beb nonato. Dgale a su mdico si usted est embarazada o planea quedar embarazada mientras est usando este medicamento.

No se sabe si la nitroglycerin pasa a la leche materna. No tome nitroglycerin sin antes consultar con su mdico si est dando de amamantar al beb. 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. Pregntele a su mdico antes usar alguna medicina para el dolor de cabeza.

Cmo debo tomar nitroglycerin

Tmelo exactamente como lo haya recetado su mdico. No lo tome en cantidades mayores o menores, o por ms tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripcin. 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 seal de un ataque, roce el aerosol sobre o debajo de su lengua. Cierre su boca despus de cada aerosol. No inhale la nebulizacin. No agite el aerosol antes o durante su uso. Usted tal vez use el aerosol varias veces cada 5 minutos, pero no use ms 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 mdico. 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 ms de 3 tabletas en 15 minutos.

Busque atencin mdica de emergencia si su dolor del pecho empeora o dura ms de 5 minutos, en particular si teme dificultad para respirar o se siente dbil, mareado, con nuseas, o siente que se puede desmayar.

Usted puede tener una sensacin leve quemante o punzante en su boca cuando use esta medicina. Sin embargo, esta sensacin no es una seal de que tan bien la medicina est trabajando. No use mas medicina solo porque usted no siente la sensacin quemante o punzante.

No triture, mastique, rompo, o abra una cpsula de liberacin extendida. Trague la pastilla entera. Ha sido preparada de forma especial para que entregue la medicina lentamente al cuerpo. Romperla o abrirla podra hacer que demasiada medicina pasa al cuerpo de forma rpida. Este medicamento puede causar resultados inusuales con ciertas pruebas mdicas. Dgale a cualquier mdico que lo atiende que usted est usando nitroglycerin. Mantenga esta medicina a la mano todo el tiempo en caso de ataque de angina. Vuelva a llenar su prescripcin 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 sbita ya que podra 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 automvil un da caluroso. El envase puede explotar se si calienta mucho.

Qu sucede si me salto una dosis?

Ya que nitroglycerin se toma cuando se necesita, usted tal vez no est en un horario de dosis. Si usted est tomando el medicamento con regularidad, tome la dosis pasada tan pronto se acuerde. Sltese la dosis pasada si su siguiente dosis la tiene que tomar en menos de 2 horas. No tome ms medicina para alcanzar la dosis pasada.

Qu sucedera en una sobredosis?

Busque atencin mdica de emergencia o llame a la lnea de Poison Help al 1-800-222-1222. Una sobredosis de nitroglycerin puede ser fatal. Los sntomas de una sobredosis pueden incluir cefalea pulstil aguda, latidos cardacos rpidos o fuertes, mareo, problemas de la visin, nusea, vmito, diarrea con sangre, dificultad al respirar, piel fra o pegajosa, sentir que se puede desmayar, desmayo, y convulsiones.

Qu debo evitar mientras tomo nitroglycerin?

Nitroglycerin puede causar efectos que perjudiquen su pensar o reacciones. Tenga cuidado si usted conduce un vehculo o tenga que hacer algo que demande se mantenga despierto y alerta.

Evite consumir alcohol. ste puede aumentar algunos de los efectos secundarios de nitroglycerin, como mareo, somnolencia, sentir que se puede desmayar, o desmayo.

Cules son los efectos secundarios posibles de la nitroglycerin?

Busque atencin mdica de emergencia si nota alguno de estos sntomas de una reaccin alrgica: ronchas, dificultad para respirar; hinchazn de la cara, labios, lengua, o garganta.

Llame a su mdico de inmediato si usted tiene un efecto secundario grave como:

paso cardaco rpido, lento, fuerte, o desigual; visin borrosa o boca seca; nusea, vmito, sudor, piel plida, sentir que se puede desmayar; o fiebre, dolor de garganta, y dolor de cabeza con una intensa presentacin en la piel de ampollas, pelarse, y sarpullido rojo.

Efectos secundarios de menor gravedad pueden incluir:

quemazn leve, sensacin 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 mdico para consejos mdicos relacionados a efectos secundarios. Usted puede reportar efectos secundarios llamando al FDA al 1-800-FDA-1088.

Qu otras drogas afectarn a la nitroglycerin?

Varias drogas pueden tener interacciones con nitroglycerin. La lista que se presenta abajo no incluye todas las drogas. Dgale a su mdico si usted est usando:

alteplase (Activase); aspirin o heparin; medicina para la vejiga o el sistema urinario como oxybutynin (Ditropan) o tolterodine (Detrol); medicina para la presin 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 psiquitricos, 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. Dgale a su mdico 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 mdico.

Dnde puedo obtener ms informacin?

Su farmacutico le puede dar ms informacin acerca de nitroglycerin.

Drug

bisacodyl

generic

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, oral avoid combo: combo may incr. risk of dehydration, electrolyte abnormalities (additive effects) [sodium phosphate, oral: sodium phosphate]

Monitor/Modify Tx

antacids separate 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 hydroxide separate 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] didanosine caution 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 hydroxide separate 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 oil separate admin. by 1h: combo w/ antacids may result in premature dissolution of entericcoating and incr. risk of GI cramps, adverse effects (absorption altered)

Caution Advised

sodium sulfate/potassium sulfate/magnesium sulfate caution 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 drugspecific 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 Action increases 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 Genrico: 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

Cul es la informacin ms importante que debo saber sobre bisacodyl?

No use bisacodyl si tiene dolor de estmago (abdomen), nusea, o vmito, salvo que su mdico le indique diferente. Si usted nota un cambio sbito en su funcionamiento de evacuacin 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 ms 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 evacuacin del intestino despus de usar un laxante puede sealar que existe algo ms grave. Deje de usar bisacodyl y comuniquese con el profesional de la salud que lo atiende.

Qu es bisacodyl?
Bisacodyl es un laxante estimulante. ste causa que los msculos del colon se contraigan y dejen pasar a la heces fecales. Bisacodyl se usa en el tratamiento del estreimiento y para la evacuacin del colon. Bisacodyl tambin puede tener otros usos diferentes a los mencionados en est gua del producto.

Qu debera discutir con el profesional de la salud antes de tomar bisacodyl?

No tome bisacodyl sin antes hablar con su mdico si tiene dolor abdominal (estmago), nusea, o vmito. Quizs no pueda tomar bisacodyl o tal vez necesite control especial. Si usted nota un cambio sbito en su funcionamiento de evacuacin 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 mdico si usted est embarazada.

No tome bisacodyl sin antes hablar con su mdico si est dando de amamantar al beb. Algunas de las preparaciones de bisacodyl han sido formuladas para el uso en nios. Hable con el mdico del nio antes de usar este producto para tratar a un nio.

Cmo debo usar bisacodyl?

Tome bisacodyl exactamente como lo indique su mdico o como lo indiquen en el paquete. Si no entiende estas instrucciones, pdale a su farmacutico, enfermera, o mdico que se las expliquen.

Tome cada dosis con un vaso de agua lleno. Trague las pastillas y las cpsulas enteras. No las mastique o las muela.

No tome las pastillas de bisacodyl dentro de una hora despus de haber tomado un anticido o leche. Bisacodyl tambin 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 (an dentro de la envoltura) bajo agua fra por uno o dos minutos antes de usarlo. Qutele 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 ms adentro en el recto.

Bisacodyl tambin 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 suspensin est 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 direccin del ombligo. Apriete la botella con consistencia para entregar todo el medicamento.

El enema de bisacodyl por lo general produce evacuacin intestinal dentro de 15 a 20 minutos. El supositorio de bisacodyl generalmente produce la evacuacin intestinal entre 15 minutos a una hora. Las pastillas de bisacodyl por lo general producen una evacuacin intestinal entre 6 a 12 horas. No tome bisacodyl por ms de una semana, salvo que su mdico le indique diferente.

Guarde bisacodyl a temperatura ambiente lejos de la humedad y el calor.

Qu 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.

Qu sucede si uso una sobredosis?

Busque atencin mdica de emergencia. Los sntomas de una sobredosis de bisacodyl no se conocen, pero pudiesen incluir nusea, vmito o dolor de estmago.

Qu debo evitar mientras uso bisacodyl?

No tome las pastillas de bisacodyl dentro de la hora despus de haber tomado un anticido o leche.

Cules 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 atencin mdica o llame de inmediato a su mdico:

una reaccin alrgica (dificultad al respirar; cierre de la garganta; hinchazn de los labios, lengua, o cara; o ronchas); sangramiento por el recto; dolor abdominal fuerte, nusea o vmito; o no tiene evacuacin intestinal.

Otros efectos secundarios de menor gravedad son ms probables de ocurrir. Siga tomando bisacodyl y hable con su mdico si siente

mareo; malestar abdominal (estmago); calambres; diarrea; o nusea leve.

Efectos secundarios diferentes a los mencionados aqu tambin pueden ocurrir. Hable con su mdico 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.

Qu otras drogas afectarn a bisacodyl?

Antes de tomar bisacodyl, dgale a su mdico si usted est tomando cualquiera de las medicinas a seguir:

un anticido o medicina para aliviar la aceda; o las medicinas para el estmago, 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).

Quizs usted no pueda tomar bisacodyl, o tal vez necesite una modificacin en su dosis o un control especial si est tomando alguna de las medicinas mencionadas arriba.

Otras drogas diferentes a las mencionadas aqu tambin pueden tener interacciones con bisacodyl. Hable con su mdico y farmacutico antes de tomar cualquier medicina, ya sea recetada o no, incluyendo los productos herbarios.

Dnde puedo obtener ms informacin?

Su farmacutico tiene ms informacin acerca de bisacodyl preparada para el uso de los profesionales de la salud que usted puede leer.

Drug

captopril
generic

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

aliskiren contraindicated 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 contraindicated 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/hydrochlorothiazide contraindicated 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/hydrochlorothiazide contraindicated 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/valsartan contraindicated 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 combos avoid 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] allopurinol caution advised, use alternative: combo may incr. risk of severe hypersensitivity rxn (mechanism unknown) ARB/thiazide combos avoid 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] ARBs avoid 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]

azathioprine use alternative: combo may incr. risk of severe leukopenia, hematologic toxicity (mechanism unknown) lithium avoid combo or monitor levels closely: combo may incr. lithium levels, risk of toxicity (renal excretion decreased)

Monitor/Modify Tx

acetaminophen/aspirin caution 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/caffeine caution 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/pamabrom caution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention) amifostine caution advised, monitor BP: combo may incr. risk of hypotension (additive effects) amlodipine/ARB combos avoid 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 combos monitor 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] antacids give 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] antipsychotics monitor 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]

aprotinin monitor BP: combo may decr. ACE inhibitor efficacy (mechanism unknown, possible antagonistic effects) aspirin/caffeine caution 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 carbonate give 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/dextromethorphan caution 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/phenylephrine caution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention) aspirin/chlorpheniramine/phenylephrine caution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention) aspirin/diphenhydramine caution 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/phenylephrine caution advised w/ high-dose aspirin or salicylates; monitor BP: combo may decr. antihypertensive efficacy (inhibition of renal prostaglandins, sodium and fluid retention) aspirin/phenylephrine caution 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 combos monitor 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 subsalicylate caution 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/tetracycline caution 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 hydroxide give 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] celecoxib monitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) CNS depressant/aspirin/caffeine combos caution 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] cyclosporine monitor potassium, renal fxn: combo may incr. risk of hyperkalemia, nephrotoxicity (additive effects) [cyclosporine: cyclosporine modified, cyclosporine non-modified] diclofenac topical monitor 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] didanosine give captopril 1h before or 4h after antacid-buffered didanosine: combo may decr. captopril levels, efficacy (absorption decreased at higher gastric pH) digoxin decr. digoxin dose 15-30% and monitor levels, toxicity: combo may incr. digoxin levels, risk of toxicity (P-glycoprotein inhibited) diuretics, loop monitor BP, use for therapeutic advantage: combo may incr. risk of hypotension (synergistic effects) [diuretics, loop: bumetanide, ethacrynic acid, furosemide, torsemide] diuretics, potassium-sparing monitor potassium: combo may incr. risk of hyperkalemia (additive effects) [diuretics, potassium-sparing: amiloride, spironolactone, triamterene] diuretics, potassium-sparing/thiazide combos monitor 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, thiazide monitor 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] drospirenone monitor potassium: combo w/ drospirenone may incr. risk of hyperkalemia (additive

effects) [drospirenone: drospirenone/estradiol, drospirenone/ethinyl estradiol, drospirenone/ethinyl estradiol/levomefolate] eplerenone caution advised, monitor BP, potassium: combo may incr. risk of hypotension, hyperkalemia (additive effects) exenatide caution advised, monitor renal fxn: combo may incr. risk of nephrotoxicity (additive toxicity) famotidine/calcium carbonate/magnesium hydroxide give captopril 1h before or 4h after: combo may decr. captopril levels, efficacy (absorption decreased) heparin monitor potassium: combo may incr. risk of hyperkalemia, risk may be greater w/ chronic heparin tx (additive effects) hydrocodone/ibuprofen monitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) ibuprofen/famotidine monitor BP, renal fxn: combo w/ ibuprofen may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) insulins monitor 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] liraglutide caution advised, monitor renal fxn: combo may incr. risk of nephrotoxicity (additive toxicity) magnesium hydroxide/mineral oil give captopril 1h before or 4h after: combo w/ antacids may decr. captopril levels, efficacy (absorption decreased) magnesium salts give 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 combos monitor glucose: combo may incr. risk of hypoglycemia (mechanism unknown, possibly incr. insulin sensitivity) [metformin/sulfonylurea combos: glipizide/metformin, glyburide/metformin] naproxen/esomeprazole monitor BP, renal fxn: combo w/ NSAIDs may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects)

nesiritide monitor BP: combo may incr. risk of hypotension (additive/synergistic effects) NSAID/chlorpheniramine/pseudoephedrine combos monitor 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 combos monitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) [NSAID/diphenhydramine combos: ibuprofen/diphenhydramine] NSAID/phenylephrine combos monitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) [NSAID/phenylephrine combos: ibuprofen/phenylephrine] NSAID/pseudoephedrine combos monitor BP, renal fxn: combo may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) [NSAID/pseudoephedrine combos: ibuprofen/pseudoephedrine, naproxen sodium/pseudoephedrine] NSAIDs monitor 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/ibuprofen monitor 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 2a caution advised, monitor CBC: combo w/ ACE inhibitor may incr. risk of granulocytopenia, thrombocytopenia (mechanism unknown, possible autoimmune destruction of myeloid precursors) polyethylene glycol/electrolytes monitor 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 citrate monitor potassium, check potassium content of supplement: combo may incr. risk of hyperkalemia (additive effects) potassium salts monitor 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] pramlintide monitor glucose: combo may incr. risk of hypoglycemia (additive/synergistic effects) probenecid monitor BP: combo may incr. ACE inhibitor duration of action, adverse effects (renal excretion decreased) salicylates caution 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 phosphates monitor renal fxn: combo may incr. risk of nephrotoxicity (overlapping toxicity) [sodium phosphates: sodium phosphate, sodium phosphate rectal] sodium sulfate/potassium sulfate/magnesium sulfate monitor renal fxn, electrolytes: combo may incr. risk of nephrotoxicity, seizures (additive effects, electrolyte abnormalities) sulfonylureas monitor glucose: combo may incr. risk of hypoglycemia (mechanism unknown, possibly incr. insulin sensitivity) [sulfonylureas: chlorpropamide, glimepiride, glipizide, glyburide, glyburide micronized, tolazamide, tolbutamide] sumatriptan/naproxen sodium monitor BP, renal fxn: combo w/ NSAIDs may decr. antihypertensive efficacy, incr. risk of nephrotoxicity (antagonistic effects, additive effects) tacrolimus monitor potassium: combo may incr. risk of hyperkalemia (additive effects) telavancin monitor renal fxn: combo may incr. risk of nephrotoxicity (additive effects) tizanidine caution advised, monitor BP: combo may incr. risk of hypotension (additive effects) tolvaptan monitor potassium: combo may incr. risk of hyperkalemia (additive effects) trandolapril/verapamil avoid duplicate tx, monitor BP, potassium, renal fxn: combo may incr. risk of hypotension, hyperkalemia, renal dysfxn (additive effects, dual blockade of renin-angiotensinaldosterone system) trimethoprim monitor potassium: combo may incr. risk of hyperkalemia (additive effects) trimethoprim/sulfamethoxazole monitor potassium: combo may incr. risk of hyperkalemia (additive effects)

Caution Advised

aldesleukin caution advised: combo may incr. risk of hypotension (additive effects) apomorphine caution advised: combo may incr. risk of orthostatic hypotension, MI, pneumonia, falls, other apomorphine adverse effects (additive effects) black cohosh caution 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] capsicum caution 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 thiomalate caution advised: combo may incr. risk of nitritoid rxn (synergistic effects) icatibant caution advised: combo may decr. ACE inhibitor efficacy (antagonistic effects) iloprost inhaled caution advised: combo may incr. risk of hypotension (additive/synergistic effects) kava caution 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-selective caution advised: combo may incr. risk of hypotension (additive effects) [MAOIs, non-selective: isocarboxazid, phenelzine, procarbazine, selegiline transdermal, tranylcypromine] maraviroc caution advised: combo may incr. risk of orthostatic hypotension (additive effects) nitrites/sodium thiosulfate caution 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 inhibitors caution advised: combo may incr. risk of symptomatic hypotension (additive effects) [PDE5 inhibitors: sildenafil, tadalafil, vardenafil] treprostinil caution 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 Action inhibits 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 Genrico: captopril Nombre de la Marca: Capoten

Cul es la informacin ms importante que debo saber sobre captopril?

No use captopril si usted est embarazada. Deje de usar este medicamento y dgale de inmediato a su mdico si queda embarazada. Captopril puede causarle dao o la muerte al beb nonato si usted toma la medicina durante su segundo o tercer trimestre.

Beber alcohol puede bajar mucho ms su presin arterial y puede aumentar ciertos efectos secundarios de captopril.

No use sustitutos de la sal o suplementos de potasio mientras est tomando captopril, salvo que su mdico le diga hacerlo. Las condiciones que pueden causar una presin arterial muy baja incluyen: vmito, diarrea, sudor excesivo, enfermedad del corazn, dilisis, una dieta baja en sal, o tomar diurticos (pastillas para eliminar el agua). Siga las instrucciones de su mdico acerca de los tipos y cantidades de lquidos que debe beber mientras est tomando captopril. Dgale a su mdico si usted tiene una enfermedad de larga duracin que le causa diarrea o vmito.

Qu es captopril?
Captopril es un inhibidor de la enzima convertidora de angiotensina (ECA; ACE, por sus siglas en Ingls). Captopril se usa en el tratamiento de la presin arterial elevada (hipertensin), falla cardiaca congestiva, problema de los riones causado por la diabetes, y para aumentar la supervivencia despus de un ataque al corazn. Captopril puede tambin usarse para fines no mencionados en esta gua del medicamento.

Qu debera 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 algn otro inhibidor ECA (ACE, por sus siglas en Ingls), as 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, dgale a su mdico si usted tiene cualquiera de estas otras condiciones:

enfermedad del rin (o si est en dilisis); enfermedad del hgado; enfermedad del corazn o falla cardiaca congestiva;

diabetes; o enfermedad del tejido conectivo, as como el sndrome de Marfan, sndrome de Sjogren, lupus, escleroderma, o artritis reumatoide.

Categora D del embarazo por la FDA. No use captopril si usted est embarazada. Deje de usar este medicamento y dgale de inmediato a su mdico si queda embarazada. Captopril puede causarle dao o la muerte al beb nonato si usted toma la medicina durante su segundo o tercer trimestre. Use un mtodo efectivo de control de la natalidad mientras estn tomando captopril.

Captopril puede pasar a la leche materna y causarle dao al beb lactante. Usted no debe amamantar mientras est usando captopril.

Cmo debo tomar captopril?

Tmelo exactamente como lo haya recetado su mdico. No lo tome en cantidades mayores o menores, o por ms tiempo de lo recomendado. Siga las instrucciones en la etiqueta de su prescripcin. Tal vez su mdico en ocasiones cambie su dosis para asegurarse de que est obteniendo los mejores resultados. Captopril por lo general se toma 1 hora antes de las comidas. Siga las instrucciones que ha recibido de su mdico.

Las condiciones que pueden causar una presin arterial muy baja incluyen: vmito, diarrea, sudor excesivo, enfermedad del corazn, dilisis, una dieta baja en sal, o tomar diurticos (pastillas para eliminar el agua). Siga las instrucciones de su mdico acerca de los tipos y cantidades de lquidos que debe beber mientras est tomando captopril. Dgale a su mdico si usted tiene una enfermedad de larga duracin que le causa diarrea o vmito. Su presin arterial necesitar ser evaluada con frecuencia. La funcin de sus riones y del hgado tambin sern examinada. Visite a su mdico con regularidad.

Si necesita ciruga, dgale al cirujano en adelantado que usted est usando captopril. Quizs necesite dejar de usar la medicina por un breve tiempo. Si usted est recibiendo tratamiento para la presin arterial alta, siga usando esta medicina aunque se sienta bien. La presin arterial alta frecuentemente no tiene sntomas. Usted tal vez necesite tomar medicina para la presin arterial el resto de su vida.

Guarde a temperatura ambiente lejos de la humedad y calor. Mantenga la botella bien cerrada cuando no se est usando.

Qu sucede si me salto una dosis?

Tome la dosis pasada tan pronto se acuerde. Sltese la dosis pasada si ya casi es hora para la siguiente dosis. No tome ms medicina para alcanzar la dosis pasada.

Qu sucedera en una sobredosis?

Busque atencin mdica de emergencia o llame a la lnea de Poison Help al 1-800-222-1222. Los sntomas de una sobredosis pueden incluir sentirse muy mareado o desmayo.

Qu debo evitar mientras tomo captopril?

Beber alcohol puede bajar mucho ms su presin arterial y puede aumentar ciertos efectos secundarios de captopril.

No use sustitutos de la sal o suplementos de potasio mientras est tomando captopril, salvo que su mdico le indique hacerlo.

Cules son los posibles efectos secundarios del captopril?

Busque atencin mdica de emergencia si usted tiene alguno de estos sntomas de una reaccin alrgica: ronchas; dolor intenso del estmago; dificultad para respirar; hinchazn de su cara, labios, lengua, o garganta.

Llame a su mdico de inmediato si usted tiene un efecto secundario grave como:

sentirse mareado, desmayo; orinar ms o menos de lo normal, o nada; fiebre, escalofros, dolor del cuerpo, sntomas de la gripe; piel plida, sentir que se va a desmayar o le falta aire al respirar, paso cardaco rpido, dificultad para concentrarse; moretones fciles, sangrado inusual (nariz, boca, vagina, o recto), manchas debajo de la piel en forma de puntos morados o rojos; latidos cardiacos desiguales, rpidos, o fuertes;

dolor de pecho; o hinchazn, ganancia de peso rpida.

Efectos secundarios de menor gravedad pueden incluir:

tos; perdida de la sensacin 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; nusea, diarrea, estreimiento; o leve picazn de la piel o sarpullido.

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

Qu otras drogas afectarn a captopril?

Dgale a su mdico 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 sanguneos, 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 Ingls) 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 diurtico (pastilla para eliminar el agua).

Esta lista no incluye todas las drogas y pueden existir otras que tengan interacciones con captopril. Dgale a su mdico 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 mdico.

Dnde puedo obtener ms informacin?

Su farmacutico le puede dar ms informacin acerca captopril (Capoten)

Drug

diphenhydramine
generic

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 chloride contraindicated 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 citrate contraindicated 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 phosphate contraindicated 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 contraindicated 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

haloperidol avoid 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, all avoid 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 iodide weigh 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) pramlintide avoid or use alternative: combo w/ anticholinergic agents may further delay gastric emptying/slow GI transit (additive effects) sodium oxybate avoid combo: combo may incr. risk of CNS depression, psychomotor impairment, adverse effects (additive effects)

Monitor/Modify Tx

dexmedetomidine caution advised, consider dose reduction: combo may incr. risk of CNS depression, other adverse effects (additive effects)

Caution Advised

acetaminophen/caffeine/CNS depressant combos caution 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/chlorpheniramine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) acetaminophen/chlorpheniramine/dextromethorphan caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) acetaminophen/chlorpheniramine/dextromethorphan/phenylephrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) acetaminophen/chlorpheniramine/phenylephrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) acetaminophen/codeine caution advised: combo w/ opioids may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive/synergistic effects) acetaminophen/diphenhydramine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) acetaminophen/diphenhydramine/dextromethorphan caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) acetaminophen/diphenhydramine/phenylephrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) acetaminophen/doxylamine/dextromethorphan caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) acetaminophen/doxylamine/dextromethorphan/phenylephrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) acetaminophen/doxylamine/dextromethorphan/pseudoephedrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

acetaminophen/doxylamine/phenylephrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) acetaminophen/pheniramine/phenylephrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) aldesleukin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) anticholinergics caution 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, ophthalmic caution advised: combo may incr. anticholinergic adverse effects (additive effects) [anticholinergics, ophthalmic: atropine ophthalmic, cyclopentolate ophthalmic, homatropine ophthalmic, scopolamine ophthalmic, tropicamide ophthalmic] antihistamine/decongestant combos caution 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, sedating caution 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] apomorphine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) aripiprazole caution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects) asenapine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) aspirin/chlorpheniramine/dextromethorphan caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx)

aspirin/chlorpheniramine/dextromethorphan/phenylephrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) aspirin/chlorpheniramine/phenylephrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) aspirin/diphenhydramine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) aspirin/doxylamine/dextromethorphan/phenylephrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) azelastine nasal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [azelastine nasal: azelastine nasal, azelastine/fluticasone propionate nasal] barbiturates caution advised: combo may incr. risk of CNS depression (additive effects) [barbiturates: butabarbital, methohexital, pentobarbital, phenobarbital, primidone, secobarbital, thiopental] benzodiazepines, all caution 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 toxins caution advised: combo may incr. risk of anticholinergic adverse effects (additive effects) [botulinum toxins: abobotulinumtoxinA, incobotulinumtoxinA, onabotulinumtoxinA, rimabotulinumtoxinB] brompheniramine/dextromethorphan/phenylephrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) brompheniramine/dextromethorphan/pseudoephedrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) buprenorphine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [buprenorphine: buprenorphine, buprenorphine transdermal, buprenorphine/naloxone] butalbital/acetaminophen caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) butorphanol caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

butorphanol nasal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) calendula caution 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] cannabinoids caution advised: combo may incr. risk of tachycardia, drowsiness, CNS depression, psychomotor impairment (additive/synergistic effects) [cannabinoids: dronabinol, nabilone] capsicum caution 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] carbamazepine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) carisoprodol/aspirin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) central alpha 2 agonists caution advised: combo may incr. risk of CNS depression (additive effects) [central alpha 2 agonists: clonidine, clonidine transdermal, guanabenz, guanfacine, methyldopa] cetirizine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (duplicate tx) cetirizine/pseudoephedrine caution advised: combo may incr. risk of CNS depression and other adverse effects (duplicate tx) chamomile, German caution 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/dextromethorphan caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) chlorpheniramine/dextromethorphan/pseudoephedrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) chlorpheniramine/hydrocodone caution advised: combo may incr. risk of CNS depression, psychomotor impairment; some antihistamines may potentiate opioid analgesic effects (additive/synergistic effects)

cholinergic agents caution advised: combo may decr. efficacy of both (antagonistic effects) [cholinergic agents: bethanechol, cevimeline, pilocarpine] cholinergic agents, ophthalmic caution advised: combo may decr. efficacy of ophthalmic cholinergic agent (antagonistic effects) [cholinergic agents, ophthalmic: carbachol ophthalmic, pilocarpine ophthalmic] clozapine caution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects) CNS depressant/aspirin/caffeine combos caution 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 ophthalmic caution advised: combo may incr. anticholinergic adverse effects (additive effects) dantrolene caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) darifenacin caution advised: combo may incr. anticholinergic adverse effects (additive effects) disopyramide caution advised: combo may incr. anticholinergic adverse effects (additive effects) doxazosin caution 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/dextromethorphan caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) droperidol caution advised: combo may incr. risk of CNS depression (additive effects) eltrombopag caution advised: combo may incr. diphenhydramine levels, risk of adverse effects (hepatic metab. inhibited) epinephrine caution advised: combo w/ diphenhydramine may incr. epinephrine adverse effects (mechanism unknown) ethanol caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) ethosuximide caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

ezogabine caution advised: combo may incr. risk of CNS depression, psychomotor impairment, urinary retention, other adverse effects (additive effects) gabapentin caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [gabapentin: gabapentin, gabapentin enacarbil] ginseng, Siberian caution 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] goldenseal caution 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 kola caution 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] hawthorn caution 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/acetaminophen caution advised: combo w/ opioids may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive/synergistic effects) hydrocodone/chlorpheniramine/pseudoephedrine caution 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/ibuprofen caution advised, consider opioid dose reduction: combo may incr. risk of severe constipation/paralytic ileus, CNS depression, psychomotor impairment, other adverse effects (additive effects) hydrocodone/pseudoephedrine caution advised, consider lower hydrocodone doses: combo of opioids and sedating antihistamines may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive effects) iloperidone caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects)

kava caution 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 balm caution 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] levocetirizine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (duplicate tx) loperamide caution advised: combo may incr. risk of severe constipation/paralytic ileus (additive effects) [loperamide: loperamide, loperamide/simethicone] loxapine caution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects) lurasidone caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) maprotiline caution advised: combo may incr. risk of CNS depression (additive effects) meprobamate caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) methadone caution advised, consider opioid dose reduction: combo may incr. risk of severe constipation/paralytic ileus, CNS depression, psychomotor impairment, other adverse effects (additive effects) metoclopramide caution advised: combo may decr. GI prokinetic effects, incr. risk of CNS depression (antagonistic effects, additive effects) mirabegron caution advised: combo w/ antihistamines may incr. risk of urinary retention, other adverse effects (additive effects) mirtazapine caution advised: combo may incr. risk of CNS depression (additive effects) mitotane caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) morphine liposomal caution advised: combo may incr. risk of CNS depression, profound sedation, other adverse effects (additive effects)

muscle relaxants caution advised: combo may incr. risk of CNS depression (additive effects) [muscle relaxants: baclofen, baclofen intrathecal, carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine, tizanidine] nalbuphine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) nefazodone caution advised: combo may incr. risk of CNS depression (additive effects) NSAID/chlorpheniramine/pseudoephedrine combos caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) [NSAID/chlorpheniramine/pseudoephedrine combos: ibuprofen/chlorpheniramine/pseudoephedrine] NSAID/diphenhydramine combos caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) [NSAID/diphenhydramine combos: ibuprofen/diphenhydramine] olanzapine caution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects) olanzapine/fluoxetine caution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects) olopatadine nasal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) opiate/aspirin combos caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [opiate/aspirin combos: carisoprodol/aspirin/codeine, oxycodone/aspirin] opiates caution 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] oxcarbazepine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) oxycodone/acetaminophen caution advised: combo w/ opioids may incr. risk of CNS depression, psychomotor impairment, other adverse effects (additive/synergistic effects)

oxycodone/ibuprofen caution advised: combo of antihistamines and opioids may incr. risk of severe constipation/paralytic ileus, CNS depression, psychomotor impairment, other adverse effects (additive effects) paliperidone caution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects) [paliperidone: paliperidone, paliperidone palmitate] passionflower caution 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 caution 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/phenylephrine caution advised: combo may incr. risk of CNS depression, anticholinergic and other adverse effects (duplicate tx) phenobarbital/hyoscyamine/atropine/scopolamine caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects) phenothiazines caution 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] pimozide caution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects) pramipexole caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) pregabalin caution advised: combo may incr. risk of CNS depression, psychomotor impairment, adverse effects (additive effects) promethazine/codeine caution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects) propofol caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [propofol: fospropofol, propofol]

propoxyphene caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [propoxyphene: propoxyphene hydrochloride, propoxyphene napsylate] propoxyphene/acetaminophen caution advised: combo w/ propoxyphene may incr. risk of CNS depression, psychomotor impairment (additive effects) [propoxyphene/acetaminophen: propoxyphene hydrochloride/acetaminophen, propoxyphene napsylate/acetaminophen] quetiapine caution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects) risperidone caution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects) ropinirole caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) rotigotine transdermal caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) rufinamide caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) sedative/hypnotics caution advised, consider sedative/hypnotic dose reduction: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [sedative/hypnotics: chloral hydrate, eszopiclone, zaleplon, zolpidem] solifenacin caution advised: combo may incr. anticholinergic adverse effects (additive effects) tamoxifen caution advised: combo w/ diphenhydramine may decr. active tamoxifen metabolite levels, efficacy (hepatic metab. inhibited) tapentadol caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) tetrabenazine caution advised: combo may incr. tetrabenazine active metabolite levels, risk of adverse effects; incr. risk of CNS depression, psychomotor impairment (hepatic metab. inhibited; additive effects) thalidomide caution advised: combo may incr. risk of CNS depression (additive effects) thiothixene caution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects)

tiagabine caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) topiramate caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [topiramate: phentermine hydrochloride/topiramate, topiramate] tramadol caution 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/acetaminophen caution advised: combo w/ tramadol may incr. risk of CNS depression, psychomotor impairment (additive effects) trazodone caution advised: combo may incr. risk of CNS depression (additive effects) tricyclic antidepressants caution 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] valerian caution 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 derivatives caution advised: combo may incr. risk of CNS depression, psychomotor impairment (additive effects) [valproic acid derivatives: divalproex sodium, valproate sodium, valproic acid] vigabatrin caution advised: combo w/ sedating antihistamines may incr. risk of CNS depression, psychomotor impairment (additive effects) ziconotide intrathecal caution advised: combo may incr. risk of confusion, dizziness, other CNS adverse effects (additive effects) [ziconotide intrathecal: ziconotide] ziprasidone caution advised: combo may incr. risk of CNS depression, psychomotor impairment, anticholinergic adverse effects (additive effects) zonisamide caution 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 Action non-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 Genrico: 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

Cul es la informacin ms importante que debo saber sobre diphenhydramine?

Tenga cuidado al conducir, al operar maquinaria, o al hacer otras actividades peligrosas. Diphenhydramine podra causar mareos o somnolencia. Si usted siente mareos o somnolencia, evite estas actividades.

Use las bebidas alcohlicas con cuidado. El alcohol podra aumentar la somnolencia y los mareos mientras est tomando diphenhydramine.

Qu es diphenhydramine?
Diphenhydramine es un antihistamnico. ste bloquea los efectos de la sustancia qumica natural histamina en su cuerpo. Diphenhydramine se usa para impedir el estornudo; nariz mucosa; ojos llorosos, con picazn; ronchas; sarpullido; picazn; y otros sntomas de alergias y del resfriado comn. Diphenhydramine tambin se usa para detener la tos, tratar los mareos causados por movimiento, inducir sueo, y para el tratamiento de la enfermedad de Parkinson de presentacin leve. Diphenhydramine podra tambin ser usada para propsitos diferentes a los que estn incluidos en esta gua del medicamento.

Qu debera 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 ltimos 14 das. Una interaccin de drogas muy peligrosa puede ocurrir, resultando en efectos secundarios de gravedad. Antes de tomar este medicamento, dgale a su mdico si usted tiene

glaucoma o elevacin de la presin en el ojo; una lcera estomacal; la prstata inflamada, problemas de la vejiga, o dificultad para orinar; la tiroides sobre activa (hipertiroidismo); presin arterial alta (hipertensin) o cualquier tipo de problema del corazn; o asma.

Quizs usted no pueda tomar diphenhydramine o tal vez necesite una dosis ms baja o un cuidado especial durante el tratamiento si tiene cualquiera de las condiciones mencionadas anteriormente.

Diphenhydramine est clasificada por la FDA en la categora B de Riesgos a la Gestacin. Esto significa que es improbable que dae al beb nonato. No tome diphenhydramine sin antes hablar con su mdico si est embarazada.

Los infantes son muy sensibles a los efectos de antihistamnicos, y efectos secundarios graves pueden ocurrir en un beb que est amamantando. Diphenhydramine no es recomendado si usted dando de amamantar. Si est amamantando al beb, no tome este medicamento sin antes consultar con su mdico. Si usted tiene ms de 60 aos de edad, es ms probable que usted note los efectos secundarios de diphenhydramine. Quizs usted necesite una dosis ms baja de este medicamento.

Cmo debo tomar la diphenhydramine?

Tome diphenhydramine exactamente como lo indique su mdico. Si no entiende estas instrucciones, pdale a su mdico, enfermera, o farmacutico 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 duracin de la exposicin al movimiento. Para ayudarlo dormir, diphenhydramine debera tomarse aproximadamente 30 minutos antes de la hora de acostarse. Para asegurar de que usted recibe la dosis correcta, mida las forma lquida 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, pregntele a su farmacutico donde puede conseguir uno.

Nunca tome ms de este medicamento de lo que le hayan prescrito. La cantidad mxima de diphenhydramine que se puede tomar en un periodo de 24 horas es (1 da) es 300 mg.

Mantenga diphenhydramine a temperatura ambiente fuera de la humedad y del calor.

Qu 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 prxima dosis, espere y tome solamente la prxima dosis regularmente fijada. No tome doble dosis de este medicamento a menos que sea indicado de lo contrario por su mdico.

Qu sucede si tomo una sobredosis?

Busque atencin mdica de emergencia. Los sntomas de una sobredosis de diphenhydramine incluyen sueo extremo, confusin, debilidad, zumbido en los odos, vista borrosa, pupilas grandes, boca seca, enrojecimiento, fiebre, temblores, insomnio, alucinaciones, y posiblemente convulsiones.

Qu debo evitar mientras tomo diphenhydramine?

Tenga cuidado al conducir, al operar maquinaria, o al hacer otras actividades peligrosas. Diphenhydramine podra causar mareos o somnolencia. Si usted siente mareos o somnolencia, evite estas actividades.

Use las bebidas alcohlicas con cuidado. El alcohol podra aumentar la somnolencia y los mareos mientras usted est tomando diphenhydramine.

Cules son los efectos secundarios posibles de diphenhydramine?

Pare de tomar diphenhydramine y busque atencin mdica de emergencia si usted nota una reaccin alrgica (dificultad para respirar; cierre de su garganta; hinchazn de sus labios, lengua, o cara; o ronchas). Otros efectos secundarios de menos importancia podran ser ms probables de ocurrir. Siga tomando diphenhydramine y consulte con su mdico si nota

sueo, cansancio, o mareos; dolor de cabeza;

boca seca; o dificultad para orinar o la prstata inflamada.

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

Que otras drogas afectarn 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 ltimos 14 das. Una interaccin de drogas muy peligrosa puede ocurrir, resultando en efectos secundarios serios. Consulte con su farmacutico antes de tomar otros medicamentos sin prescripcin para la tos, resfriado, alergia, o insomnio. stos productos podran contener medicamentos similares a diphenhydramine, lo cual puede resultar en una sobredosis de antihistamnicos. Antes de tomar este medicamento, dgale a su mdico si usted est 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, sooliento, o relajado.

Adems de las drogas mencionadas anteriormente, otras tambin podran tener interacciones con diphenhydramine. Consulte con su mdico y farmacutico antes de tomar cualquier medicamento, ya sea recetado o no.

Dnde puedo obtener ms informacin?

Su farmacutico tiene ms informacin acerca de diphenhydramine (Benadryl).