IO Resep

Interactions between your selected drugs
Major
rifampin pyrazinamide
Applies to: rifampin, pyrazinamide
GENERALLY AVOID: A two-month regimen consisting of rifampin (RIF) and

pyrazinamide (PZA) for the treatment of latent tuberculosis infection (LTBI) has been
associated with liver injury resulting in high rates of hospitalization and death. The exact
mechanism of interaction is unknown, although both agents are individually hepatotoxic
and may have additive effects on the liver during coadministration. In one prospective
cohort study of 224 patients in a community setting between 1999 and 2001,
investigators found that the risk of hepatotoxicity in patients receiving the RIF-PZA
regimen was increased threefold compared to patients receiving six months of isoniazid
(INH). When patients were monitored more intensively, severe hepatotoxicity did not
develop, but the difference did not reach statistical significance.
MANAGEMENT: The American Thoracic Society and the Centers for Disease Control
and Prevention recommend that the two-month RIF-PZA regimen generally not be
offered to patients with LTBI (Note: This recommendation does not apply to the
appropriate use of RIF and PZA in multidrug regimens for the treatment of persons with
active TB disease). A nine-month course of daily INH remains the preferred treatment
for LTBI in both HIV-negative and HIV-positive patients. Other acceptable options
include nine months of twice-weekly INH, or six months of either daily or twice-weekly
INH. Twice-weekly therapy must be administered under direct observed therapy (DOT),
and the six-month regimens should generally not be used in HIV-infected individuals,
those with fibrotic lesions on chest radiographs, and children. Four months of daily RIF
may be considered for persons who are contacts of patients with INH-resistant, RIFsusceptible TB. The RIF-PZA regimen should never be offered to patients who are
taking concomitant medications associated with liver injury; patients who drink alcohol
excessively (even if alcohol use is discontinued during treatment); patients with
underlying liver disease; and patients with a history of INH-associated liver injury. RIFPZA may be considered in carefully selected patients if there is reason to believe they
are not likely to complete the preferred six- or nine-month regimens. If RIF-PZA is
prescribed, the PZA dosage should be no more than 20 mg/kg/day (up to a maximum of
2 g/day) or 50 mg/kg twice weekly (up to a maximum of 4 g twice weekly), and no more
than a two-week supply of the medications should be dispensed at any given time.
Patients should be evaluated in person by a healthcare provider at 2, 4, and 6 weeks of

treatment for adherence, tolerance and adverse effects, and at 8 weeks to document
treatment completion. Patients should also be instructed to discontinue the drugs
promptly and seek medical attention if signs and symptoms of hepatic injury develop,
including fever, rash, anorexia, nausea, vomiting, fatigue, right upper quadrant pain,
dark urine, and jaundice. Serum transaminases and bilirubin should be measured at
baseline and at 2, 4, 6, and 8 weeks of treatment in patients taking RIF-PZA. Therapy
should be withdrawn and not resumed if transaminase levels exceed five times the
upper limit of normal or are anywhere above the normal range when accompanied by
symptoms of hepatitis, or if serum bilirubin is greater than the normal range. U.S.
healthcare providers should report possible cases of RIF-PZA hepatotoxicity to CDC's
Division of Tuberculosis Elimination, telephone 404-639-8442.
References
1.
Kunimoto D, Warman A, Beckon A, Doering D, Melenka L "Severe hepatotoxicity associated with

rifampin-pyrazinamide preventative therapy requiring transplantation in an individual at low risk for
hepatotoxicity." Clin Infect Dis 36 (2003): E158-61
2.
"Update: Fatal and severe liver injuries associated with rifampin and pyrazinamide treatment for latent
tuberculosis infection." MMWR Morb Mortal Wkly Rep 51 (2002): 998-9
3.
CDC. Centers for Disease Control and Prevention. "Update: Adverse event data and revised American
Thoracic Society/CDC recommendations against the use of rifampin and pyrazinamide for treatment of
latent tuberculosis infection--United States, 2003." MMWR Morb Mortal Wkly Rep 52 (2003): 735-9
View all 6 references
Switch to consumer interaction data
Major
haloperidol ondansetron
Applies to: haloperidol, ondansetron
MONITOR CLOSELY: Haloperidol can cause dose-related prolongation of the QT

interval. Theoretically, coadministration with other agents that can prolong the QT
interval may result in additive effects and increased risk of ventricular arrhythmias
including torsade de pointes and sudden death. Haloperidol treatment alone has been
associated with a number of reported cases of torsade de pointes and sudden death.
The majority of cases involved intravenous administration or use of higher than
recommended dosages. In general, the risk of an individual agent or a combination of
agents causing ventricular arrhythmia in association with QT prolongation is largely
unpredictable but may be increased by certain underlying risk factors such as congenital
long QT syndrome, cardiac disease, and electrolyte disturbances (e.g., hypokalemia,
hypomagnesemia). The extent of drug-induced QT prolongation is dependent on the
particular drug(s) involved and dosage(s) of the drug(s). In addition, certain agents with
anticholinergic properties (e.g., sedating antihistamines; antispasmodics; neuroleptics;
phenothiazines; skeletal muscle relaxants; tricyclic antidepressants) may have additive
parasympatholytic and central nervous system-depressant effects when used in
combination with haloperidol. Excessive parasympatholytic effects may include paralytic
ileus, hyperthermia, mydriasis, blurred vision, tachycardia, urinary retention, psychosis,
and seizures.
MANAGEMENT: Caution is recommended if haloperidol is used in combination with
other drugs that can prolong the QT interval, particularly when administered
intravenously or at higher than recommended dosages. Haloperidol is not approved by
the FDA for intravenous administration. Patients should be advised to seek prompt
medical attention if they experience symptoms that could indicate the occurrence of
torsade de pointes such as dizziness, lightheadedness, fainting, palpitation, irregular
heart rhythm, shortness of breath, or syncope. In addition, if combination therapy with
agents with anticholinergic properties is required, caution is advised, particularly in the
elderly and those with underlying organic brain disease. Patients should be advised to
notify their physician promptly if they experience potential symptoms of anticholinergic
intoxication such as abdominal pain, fever, heat intolerance, blurred vision, confusion,
and/or hallucinations. Ambulatory patients should be counseled to avoid activities
requiring mental alertness until they know how these agents affect them. A reduction in
anticholinergic dosages may be necessary if excessive adverse effects develop.
References
1.
Huyse F, van Schijndel RS "Haloperidol and cardiac arrest." Lancet 2 (1988): 568-9
2.
Canadian Pharmacists Association "e-CPS. Available from: URL:

http://www.pharmacists.ca/function/Subscriptions/ecps.cfm?link=eCPS_quikLink."
3.
"Product Information. Haldol (haloperidol)." McNeil Pharmaceutical, Raritan, NJ.
Major
haloperidol azithromycin
Applies to: haloperidol, azithromycin
MONITOR CLOSELY: Haloperidol can cause dose-related prolongation of the QT

interval. Theoretically, coadministration with other agents that can prolong the QT
interval may result in additive effects and increased risk of ventricular arrhythmias
including torsade de pointes and sudden death. Haloperidol treatment alone has been
associated with a number of reported cases of torsade de pointes and sudden death.
The majority of cases involved intravenous administration or use of higher than
recommended dosages. In general, the risk of an individual agent or a combination of
agents causing ventricular arrhythmia in association with QT prolongation is largely
unpredictable but may be increased by certain underlying risk factors such as congenital
long QT syndrome, cardiac disease, and electrolyte disturbances (e.g., hypokalemia,
hypomagnesemia). The extent of drug-induced QT prolongation is dependent on the
particular drug(s) involved and dosage(s) of the drug(s). In addition, certain agents with
anticholinergic properties (e.g., sedating antihistamines; antispasmodics; neuroleptics;
phenothiazines; skeletal muscle relaxants; tricyclic antidepressants) may have additive
parasympatholytic and central nervous system-depressant effects when used in
combination with haloperidol. Excessive parasympatholytic effects may include paralytic
ileus, hyperthermia, mydriasis, blurred vision, tachycardia, urinary retention, psychosis,
and seizures.
MANAGEMENT: Caution is recommended if haloperidol is used in combination with
other drugs that can prolong the QT interval, particularly when administered
intravenously or at higher than recommended dosages. Haloperidol is not approved by
the FDA for intravenous administration. Patients should be advised to seek prompt
medical attention if they experience symptoms that could indicate the occurrence of
torsade de pointes such as dizziness, lightheadedness, fainting, palpitation, irregular
heart rhythm, shortness of breath, or syncope. In addition, if combination therapy with
agents with anticholinergic properties is required, caution is advised, particularly in the
elderly and those with underlying organic brain disease. Patients should be advised to
notify their physician promptly if they experience potential symptoms of anticholinergic
intoxication such as abdominal pain, fever, heat intolerance, blurred vision, confusion,
and/or hallucinations. Ambulatory patients should be counseled to avoid activities
requiring mental alertness until they know how these agents affect them. A reduction in
anticholinergic dosages may be necessary if excessive adverse effects develop.
References
1.
Huyse F, van Schijndel RS "Haloperidol and cardiac arrest." Lancet 2 (1988): 568-9
2.

3.
"Product Information. Haldol (haloperidol)." McNeil Pharmaceutical, Raritan, NJ.
Major
rifampin isoniazid
Applies to: rifampin, isoniazid
MONITOR CLOSELY: The risk of hepatotoxicity is greater when rifampin and isoniazid
are given concomitantly than when either drug is given alone. Rifampin appears to alter
the metabolism of isoniazid and increase the amount of toxic metabolites. Theoretically,
a similar reaction may occur with rifabutin and isoniazid. Patients who are elderly, have
hepatic impairment, are slow acetylators of isoniazid, drink alcohol daily, are female, or
are taking other strong CYP450-inducing agents may be at greater risk of
hepatotoxicity.
MANAGEMENT: Close monthly monitoring for clinical or laboratory evidence of altered
hepatic function is recommended. Patients should be advised to promptly report early
symptoms of hepatitis such as fatigue, weakness, malaise, anorexia, nausea, or
vomiting. Discontinuation of either or both drugs may be necessary.
References
1.
Askgaard DS, Wilcke T, Dossing M "Hepatotoxicity caused by the combined action of isoniazid and
rifampicin." Thorax 50 (1995): 213-4
2.
"Product Information. Mycobutin (rifabutin)." Pharmacia and Upjohn, Kalamazoo, MI.
3.
Yamamoto T, Suou T, Hirayama C "Elevated serum aminotransferase induced by isoniazid in relation to

isoniazid acetylator phenotype." Hepatology 6 (1986): 295-8
Moderate
rifampin ondansetron
Applies to: rifampin, ondansetron
MONITOR: Concomitant use of rifamycin derivatives with ondansetron may result in a

reduced antiemetic effect, particularly after the oral administration of ondansetron. The
proposed mechanism is induction of the CYP450 3A4/1A2 mediated metabolism of
ondansetron.
MANAGEMENT: Patients should be monitored for reduced antiemetic effects and the
ondansetron dose adjusted as necessary.
References
1.
Villikka K, Kivisto KT, Neuvonen PJ "The effect of rifampin on the pharmacokinetics of oral and
intravenous ondansetron." Clin Pharmacol Ther 65 (1999): 377-81
Moderate
azithromycin ondansetron
Applies to: azithromycin, ondansetron
MONITOR: Theoretically, concurrent use of two or more drugs that can cause QT
interval prolongation may result in additive effects and increased risk of ventricular
arrhythmias including torsade de pointes and sudden death. The risk of an individual
agent or a combination of these agents causing ventricular arrhythmia in association
with QT prolongation is largely unpredictable but may be increased by certain
underlying risk factors such as congenital long QT syndrome, cardiac disease, and
electrolyte disturbances (e.g., hypokalemia, hypomagnesemia). In addition, the extent of
drug-induced QT prolongation is dependent on the particular drug(s) involved and
dosage(s) of the drug(s).
MANAGEMENT: Caution and clinical monitoring are recommended if multiple agents
associated with QT interval prolongation are prescribed together. Patients should be
advised to seek prompt medical attention if they experience symptoms that could
indicate the occurrence of torsade de pointes such as dizziness, lightheadedness,
fainting, palpitation, irregular heart rhythm, shortness of breath, or syncope.
References
1.
EMA. European Medicines Agency. European Union "European Medicines Agency. Available from:
URL: http://www.ema.europa.eu/ema/index.jsp?
curl=pages/regulation/document_listing/document_listing_000366.jsp&mid=WC0b01ac058067c852"
([2013 - ]):
2.
Glassman AH, Bigger JT Jr "Antipsychotic drugs: prolonged QTc interval, torsade de pointes, and
sudden death." Am J Psychiatry 158 (2001): 1774-82
3.

Moderate
ondansetron phenolphthalein
Applies to: ondansetron, phenolphthalein
MONITOR: Bowel cleansing as well as overuse of certain laxatives may cause

electrolyte loss and increase the risk of torsade de pointes ventricular arrhythmia in
patients treated with drugs that prolong the QT interval. Electrolyte disturbances
including hypokalemia and hypomagnesemia have been reported with laxative abuse
and are known risk factors for torsade de pointes associated with QT interval
prolongation.
MANAGEMENT: Patients treated with drugs that prolong the QT interval should exercise
caution when self-medicating with laxatives. The recommended dosage and duration of
use should not be exceeded. Patients treated with lactulose for more than six months
should be monitored periodically for electrolyte imbalance. Patients should be advised to
seek prompt medical attention if they experience symptoms that could indicate the
occurrence of torsade de pointes such as dizziness, lightheadedness, fainting,
palpitation, irregular heart rhythm, shortness of breath, or syncope.
References
1.
Cerner Multum, Inc. "Australian Product Information." O 0
2.
Cerner Multum, Inc. "UK Summary of Product Characteristics." O 0
3.
Schaefer DC, Cheskin LJ "Constipation in the elderly." Am Fam Physician 58 (1998): 907-14
Moderate
rifampin methylprednisolone
Applies to: rifampin, methylprednisolone
MONITOR: Rifampin may induce the hepatic metabolism of corticosteroids, possibly

reducing their therapeutic effect. The elimination half-life of corticosteroids has been
shown to be reduced by up to 45% when rifampin is coadministered. Theoretically,
rifabutin could interact with corticosteroids in a similar manner.
MANAGEMENT: Patients should be monitored for altered corticosteroid effects. Dosage
increases may be necessary. Two- to threefold increases in prednisolone dosage have
been recommended.
References
1.
Lee KH, Shin JG, Chong WS, Kim S, Lee JS, Jang IJ, Shin SG "Time course of the changes in
prednisolone pharmacokinetics after co-administration or discontinuation of rifampin." Eur J Clin
Pharmacol 45 (1993): 287-9
2.
Venkatesan K "Pharmacokinetic drug interactions with rifampicin." Clin Pharmacokinet 22 (1992): 4765
3.
Kyriazopoulou V, Parparousi O, Vagenakis AG "Rifampicin-induced adrenal crisis in Addisonian

patients receiving corticosteroid replacement therapy." J Clin Endocrinol Metab 59 (1984): 1204-6
Moderate
haloperidol phenolphthalein
Applies to: haloperidol, phenolphthalein

prolongation.

References
1.
2.
3.
Moderate
acetaminophen isoniazid
Applies to: acetaminophen, isoniazid
MONITOR: Some reports have suggested that isoniazid may increase the potential
hepatotoxicity of acetaminophen. The mechanism may be related to induction of
CYP450 2E1 metabolism of acetaminophen to toxic metabolites during concurrent
administration, or transient increased metabolism of acetaminophen after
discontinuation of isoniazid. Study data have been conflicting and causality is unclear
due to the presence of other drugs in some cases. Both isoniazid and acetaminophen
have individually been associated with hepatotoxicity.
MANAGEMENT: Until more information is available, concurrent acetaminophen use
should be limited. Close attention should be paid to clinical and laboratory evidence of
hepatotoxicity. Both drugs should be discontinued if evidence of hepatoxicity is
observed. Aspirin or nonsteroidal inflammatory agents may be safer alternatives.
References
1.
Murphy R, Swartz R, Watkins PB "Severe acetaminophen toxicity in a patient receiving isoniazid." Ann
Intern Med 113 (1990): 799-800
2.
Nolan CM, Sandblom RE, Thummel KE, Slattery JT, Nelson SD "Hepatotoxicity associated with
acetaminophen usage in patients receiving multiple drug therapy for tuberculosis." Chest 105 (1994): 40811
3.
Epstein MM, Nelson SD, Slattery JT, Kalhorn TF, Wall RA, Wright JM "Inhibition of the metabolism of
paracetamol by isoniazid." Br J Clin Pharmacol 31 (1991): 139-42
Moderate
azithromycin phenolphthalein
Applies to: azithromycin, phenolphthalein

prolongation.
References
1.
2.
3.
Moderate
ethambutol isoniazid
Applies to: ethambutol, isoniazid
MONITOR: The risk of peripheral neuropathy may be increased during concurrent use
of two or more agents that are associated with this adverse effect. Patient risk factors
include diabetes and age older than 60 years. In some cases, the neuropathy may
progress or become irreversible despite discontinuation of the medications.
MANAGEMENT: Caution is advised during concomitant use of agents with neurotoxic
effects. Patients should be monitored closely for symptoms of neuropathy such as

burning, tingling, pain, or numbness in the hands and feet. Since the development of
peripheral neuropathy may be dose-related for many drugs, the recommended dosages
should generally not be exceeded. Consideration should be given to dosage reduction
or immediate discontinuation of these medications in patients who develop peripheral
neuropathy to limit further damage. If feasible, therapy should generally be reinstituted
only after resolution of neuropathy symptoms or return of symptoms to baseline status.
In some cases, permanent dosage reductions may be required.
References
1.
Argov Z, Mastaglia FL "Drug-induced peripheral neuropathies." Br Med J 1 (1979): 663-6
2.
Carrion C, Espinosa E, Herrero A, Garcia B "Possible vincristine-isoniazid interaction." Ann

Pharmacother 29 (1995): 201
3.
Pharmaceutical Society of Australia "APPGuide online. Australian prescription products guide online.
Available from: URL: http://www.appco.com.au/appguide/default.asp." ([2006]):
Moderate
methylprednisolone phenolphthalein
Applies to: methylprednisolone, phenolphthalein
MONITOR: The overuse or abuse of laxatives can cause significant loss of electrolytes
and potentiate the risk of hypokalemia associated with corticosteroid therapy.
Corticosteroids promote the retention of sodium and water and the excretion of
potassium. Although these effects are primarily associated with mineralocorticoids like
fludrocortisone, they may also occur with higher dosages of glucocorticoids or
adrenocorticotropic agents, particularly if given systemically for longer than brief
periods.
MANAGEMENT: In general, laxatives should only be used on a short-term, intermittent
basis in recommended dosages. During concomitant therapy with corticosteroids,
particularly if fludrocortisone or large doses of a glucocorticoid or adrenocorticotropic
agent is given, patients should be counseled to recognize potential signs and symptoms
of hypokalemia such as fatigue, myalgia, and muscle weakness. If maintenance of
bowel regularity is required, patients should be advised to exercise and increase fiber in
the diet and/or consider the use of bulk-forming laxatives.
References
1.
Chin RL "Laxative-induced hypokalemia." Ann Emerg Med 32 (1998): 517-8
2.
Blumenthal M, Goldberg A, Brinckmann J, eds. "Herbal Medicine: Expanded Commission E

Monographs." Newton, MA: Integrative Medicine Communications (2000):
3.
Seale JP, Compton MR "Side-effects of corticosteroid agents." Med J Aust 144 (1986): 139-42
Moderate
haloperidol methylphenidate
Applies to: haloperidol, methylphenidate
GENERALLY AVOID: Butyrophenone neuroleptics may antagonize the pharmacologic

effects of amphetamine, amphetamine derivatives, and other centrally-acting
sympathomimetic agents (i.e., CNS stimulants). Conversely, these agents may diminish
the neuroleptic efficacy of butyrophenones. The exact mechanism of interaction is
unknown but may involve opposing effects on dopaminergic activity. Several clinical
studies have demonstrated the reduction or lack of effect of amphetamines on weight
loss in obese psychiatric patients treated with haloperidol and other neuroleptic agents,
most notably chlorpromazine. In one of these studies, dextroamphetamine also had no
effect on sleep patterns. Another study found haloperidol to inhibit amphetamineinduced symptoms and may be useful in amphetamine intoxication. As for the reverse
interaction, it is uncertain whether CNS stimulants actually antagonize the neuroleptic
effect of butyrophenones, since CNS stimulants alone have been reported to cause or
aggravate preexisting psychotic symptoms. There has also been a report of acute
dystonia occurring in two normal, healthy young women given haloperidol and
dexamphetamine as part of a neuropharmacological study. The authors postulated that
the reaction was due to a potentiation of dopamine release.
MANAGEMENT: Amphetamine, amphetamine derivatives, and other CNS stimulants
should generally not be used, particularly for weight reduction, in patients treated with a
butyrophenone neuroleptic agent.
References
1.
Reid AA "Pharmacological antagonism between chlorpromazine and phenmetrazine in mental hospital

patients." Med J Aust 1 (1964): 187-8
2.
"Product Information. Vyvanse (lisdexamfetamine)." Shire US Inc, Florence, KY.
3.
Achor MB, Extein I "Diet aids, mania, and affective illness" Am J Psychiatry 138 (1981): 392
Minor
isoniazid methylprednisolone
Applies to: isoniazid, methylprednisolone
Serum concentrations of isoniazid may be reduced and corticosteroid levels may be

increased during concomitant administration of corticosteroids. The mechanism is
unknown, but may involve enhanced hepatic and/or renal elimination of isoniazid and
decreased hepatic metabolism of corticosteroids. Fast acetylators of isoniazid may be at
a greater risk for this interaction. The clinical significance is unknown. Patients receiving
concurrent corticosteroids and isoniazid should be monitored for decreased isoniazid
effectiveness and increased corticosteroid effects.
References
1.
Brodie MJ, Boobis AR, Hillyard CJ, Abeyasekera G, MacIntyre I, Park BK "Effect of isoniazid on
vitamin D metabolism and hepatic monooxygenase activity." Clin Pharmacol Ther 30 (1981): 363-7
2.
Sarma G, Kailasam S, Nair NG, Narayana AS, Tripathy SP "Effect of prednisonlone and refampin on
isoniazid metabolism in slow and rapid inactivators of isoniazid." Antimicrob Agents Chemother 18 (1980):
661-6
Minor
haloperidol isoniazid
Applies to: haloperidol, isoniazid
Isoniazid may increase serum haloperidol levels. The mechanism may be related to
inhibition of hepatic metabolism of haloperidol. Close observation for alterations in
haloperidol effect is indicated if these drugs must be used together.
References
1.
Takeda M, Nishinuma K, Yamashita S, et al "Serum haloperidol levels of schizophrenics receiving

treatment for tuberculosis." Clin Neuropharmacol 9 (1986): 386-97
Minor
rifampin acetaminophen
Applies to: rifampin, acetaminophen
Rifampin may slightly decrease the therapeutic effects of acetaminophen, although at

usual doses, no intervention appears to be necessary. Additionally, rifampin may
increase the risk of hepatotoxicity in patients taking acetaminophen and isoniazid.
References
1.
Nolan CM, Sandblom RE, Thummel KE, Slattery JT, Nelson SD "Hepatotoxicity associated with
acetaminophen usage in patients receiving multiple drug therapy for tuberculosis." Chest 105 (1994): 40811
2.
Bock KW, Wiltfang J, Blume R, Ullrich D, Bircher J "Paracetamol as a test drug to determine
glucuronide formation in man: effects of inducers and of smoking." Eur J Clin Pharmacol 31 (1987): 67783
3.
Prescott LF, Critchley JA, Balali-Mood M, Pentland B "Effects of microsomal enzyme induction on
paracetamol metabolism in man." Br J Clin Pharmacol 12 (1981): 149-53
Minor
haloperidol rifampin
Applies to: haloperidol, rifampin
Rifampin may reduce serum butyrophenone concentrations. The mechanism may be

related to induction of CYP450 metabolism. Data exist only for rifampin, but this
interaction may also occur with rifabutin. The clinical significance is unknown.
Observation for alteration in response to haloperidol is indicated if these drugs must be
used together.
References
1.
Takeda M, Nishinuma K, Yamashita S, et al "Serum haloperidol levels of schizophrenics receiving

treatment for tuberculosis." Clin Neuropharmacol 9 (1986): 386-97
2.
Strayhorn VA, Baciewicz AM, Self TH "Update on rifampin drug interactions, III." Arch Intern Med 157
(1997): 2453-8
3.
Borcherding SM, Baciewicz AM, Self TH "Update on rifampin drug interactions." Arch Intern Med 152
(1992): 711-6
No other interactions were found between your selected drugs.

Note: this does not necessarily mean no interactions exist. ALWAYS consult with your
doctor or pharmacist.
Other drugs that your selected drugs interact with
acetaminophen interacts with more than 80 other drugs.
azithromycin interacts with more than 200 other drugs.
ethambutol interacts with more than 90 other drugs.
haloperidol interacts with more than 500 other drugs.
isoniazid interacts with more than 200 other drugs.
methylphenidate interacts with more than 100 other drugs.
methylprednisolone interacts with more than 400 other drugs.
ondansetron interacts with more than 200 other drugs.
phenolphthalein interacts with more than 100 other drugs.
pyrazinamide interacts with more than 20 other drugs.
pyridoxine interacts with more than 10 other drugs.
rifampin interacts with more than 400 other drugs.
Glaucon (epinephrine ophthalmic) interacts with more than 40 other drugs.
Interactions between your selected drugs and food

Moderate
methylphenidate food
Applies to: methylphenidate
GENERALLY AVOID: Alcohol may exacerbate the adverse central nervous system
effects of psychoactive drugs, including methylphenidate.
GENERALLY AVOID: Consumption of alcohol while taking certain sustained-release
formulations of methylphenidate may cause rapid release of the drug, resulting in
increased systemic levels of methylphenidate. In vitro studies have been conducted
using Metadate CD 60 mg and Ritalin LA 40 mg capsules, as well as Concerta 18 mg
tablet. At an alcohol concentration of 40%, an increase in the release rate of
methylphenidate was observed in the first hour for Metadate CD and Ritalin LA,
resulting in 84% and 98% of the methylphenidate being released, respectively. In
contrast, there was no increased release of methylphenidate in the first hour for
Concerta. These results are considered to be representative of the other available
strengths of the corresponding product.
MANAGEMENT: Patients treated with methylphenidate should be advised to avoid
alcohol or medications that contain alcohol.
References
1.
"Product Information. Ritalin LA (methylphenidate)." Quality Care Products/Lake Erie Medical ,

Temperance, MI.
2.
"Product Information. Concerta (methylphenidate)." Alza, Palo Alto, CA.
3.
"Product Information. Metadate CD Capsules (methylphenidate)" Celltech Pharmaceuticals, Inc,

Applegate, WI.
Moderate
haloperidol food
Applies to: haloperidol
GENERALLY AVOID: Alcohol may potentiate some of the pharmacologic effects of

CNS-active agents. Use in combination may result in additive central nervous system
depression and/or impairment of judgment, thinking, and psychomotor skills.
MANAGEMENT: Patients receiving CNS-active agents should be warned of this
interaction and advised to avoid or limit consumption of alcohol. Ambulatory patients
should be counseled to avoid hazardous activities requiring complete mental alertness
and motor coordination until they know how these agents affect them, and to notify their
physician if they experience excessive or prolonged CNS effects that interfere with their
normal activities.
References
1.
Gilman AG, Rall TW, Nies AS, Taylor P, eds. "Goodman and Gilman's the Pharmacological Basis of
Therapeutics. 8th ed." New York, NY: Pergamon Press Inc. (1990):
2.
"Product Information. Fycompa (perampanel)." Eisai Inc, Teaneck, NJ.
3.
Warrington SJ, Ankier SI, Turner P "Evaluation of possible interactions between ethanol and trazodone
or amitriptyline." Neuropsychobiology 15 (1986): 31-7
Moderate
methylprednisolone food
Applies to: methylprednisolone
MONITOR: Grapefruit juice may increase the plasma concentrations of orally

administered drugs that are substrates of the CYP450 3A4 isoenzyme. However, the
interaction seems to affect primarily those drugs that undergo significant presystemic
metabolism by CYP450 3A4 (i.e., drugs with low oral bioavailability), presumably due to
the fact that grapefruit juice inhibits primarily intestinal rather than hepatic CYP450 3A4.
Because pharmacokinetic interactions involving grapefruit juice are often subject to a
high degree of interpatient variability, the extent to which a given patient may be affected
is difficult to predict.
MANAGEMENT: Patients who regularly consume grapefruit or grapefruit juice should be
monitored for adverse effects and altered plasma concentrations of drugs that undergo
significant presystemic metabolism by CYP450 3A4. Grapefruit and grapefruit juice
should be avoided if an interaction is suspected. Orange juice is not expected to interact
with these drugs.
References
1.
Gunston GD, Mehta U "Potentially serious drug interactions with grapefruit juice." S Afr Med J 90
(2000): 41
2.
Bailey DG, Dresser GR, Kreeft JH, Munoz C, Freeman DJ, Bend JR "Grapefruit-felodipine interaction:
Effect of unprocessed fruit and probable active ingredients." Clin Pharmacol Ther 68 (2000): 468-77
3.
Bailey DG, Arnold JMO, Spence JD "Grapefruit juice and drugs - how significant is the interaction."
Clin Pharmacokinet 26 (1994): 91-8
Moderate
isoniazid food
Applies to: isoniazid
ADJUST DOSING INTERVAL: Administration with food significantly reduces isoniazid

absorption, increasing the risk of therapeutic failure or resistance. The mechanism is
unknown. In addition, the ingestion of certain histamine-rich fish (e.g., tuna) and
cheeses during isoniazid therapy may cause a flushing reaction in some patients. The
proposed mechanism is inhibition of monoamine oxidase and histaminase by isoniazid,
resulting in histamine intoxication.
MANAGEMENT: Isoniazid should be administered on an empty stomach, one hour
before or two hours after meals. Patients who experience symptoms such as flushing,
tachycardia, chills, headache, nausea, vomiting, diarrhea, burning sensations, sweating,
or shortness of breath after eating certain foods should be advised to avoid them.
References
1.
"Product Information. INH (isoniazid)." Ciba Pharmaceuticals, Summit, NJ.
2.
Smith CK, Durack DT "Isoniazid and reaction to cheese." Ann Intern Med 88 (1978): 520-1
3.
Uragoda CG, Kottegoda SR "Adverse reactions to isoniazid on ingestion of fish with a high histamine
content." Tubercle 58 (1977): 83-9
Therapeutic duplication warnings

Therapeutic duplication is the use of more than one medicine from the same drug category or
therapeutic class to treat the same condition. This can be intentional in cases where drugs with
similar actions are used together for demonstrated therapeutic benefit. It can also be unintentional in
cases where a patient has been treated by more than one doctor, or had prescriptions filled at more
than one pharmacy, and can have potentially adverse consequences.
Duplication
Anti-infectives
Therapeutic duplication
The recommended maximum number of medicines in the 'anti-infectives' category to be

taken concurrently is usually three. Your list includes five medicines belonging to the
'anti-infectives' category:
azithromycin
ethambutol
isoniazid
pyrazinamide
rifampin
Note: The benefits of taking this combination of medicines may outweigh any risks
associated with therapeutic duplication. This information does not take the place of
talking to your doctor. Always check with your healthcare provider to determine if any
adjustments to your medications are needed.
Duplication
Miscellaneous antituberculosis agents

The recommended maximum number of medicines in the 'miscellaneous

antituberculosis agents' category to be taken concurrently is usually one. Your list
includes two medicines belonging to the 'miscellaneous antituberculosis agents'
category:
ethambutol
pyrazinamide
Duplication
Antituberculosis agents
The recommended maximum number of medicines in the 'antituberculosis agents'

category to be taken concurrently is usually three. Your list includes four medicines
belonging to the 'antituberculosis agents' category:
ethambutol
isoniazid
pyrazinamide
rifampin

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Interactions between your selected drugs

GENERALLY AVOID: A two-month regimen consisting of rifampin (RIF) and

Patients should be evaluated in person by a healthcare provider at 2, 4, and 6 weeks of

Kunimoto D, Warman A, Beckon A, Doering D, Melenka L "Severe hepatotoxicity associated with

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MONITOR CLOSELY: Haloperidol can cause dose-related prolongation of the QT

Canadian Pharmacists Association "e-CPS. Available from: URL:

"Product Information. Haldol (haloperidol)." McNeil Pharmaceutical, Raritan, NJ.

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Applies to: haloperidol, azithromycin

MONITOR CLOSELY: Haloperidol can cause dose-related prolongation of the QT

Canadian Pharmacists Association "e-CPS. Available from: URL:

"Product Information. Haldol (haloperidol)." McNeil Pharmaceutical, Raritan, NJ.

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"Product Information. Mycobutin (rifabutin)." Pharmacia and Upjohn, Kalamazoo, MI.

Yamamoto T, Suou T, Hirayama C "Elevated serum aminotransferase induced by isoniazid in relation to

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MONITOR: Concomitant use of rifamycin derivatives with ondansetron may result in a

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Canadian Pharmacists Association "e-CPS. Available from: URL:

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MONITOR: Bowel cleansing as well as overuse of certain laxatives may cause

Cerner Multum, Inc. "Australian Product Information." O 0

Cerner Multum, Inc. "UK Summary of Product Characteristics." O 0

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MONITOR: Rifampin may induce the hepatic metabolism of corticosteroids, possibly

Kyriazopoulou V, Parparousi O, Vagenakis AG "Rifampicin-induced adrenal crisis in Addisonian

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MONITOR: Bowel cleansing as well as overuse of certain laxatives may cause

occurrence of torsade de pointes such as dizziness, lightheadedness, fainting,

Cerner Multum, Inc. "Australian Product Information." O 0

Cerner Multum, Inc. "UK Summary of Product Characteristics." O 0

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View all 5 references

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MONITOR: Bowel cleansing as well as overuse of certain laxatives may cause

Cerner Multum, Inc. "Australian Product Information." O 0

Cerner Multum, Inc. "UK Summary of Product Characteristics." O 0

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effects. Patients should be monitored closely for symptoms of neuropathy such as

Argov Z, Mastaglia FL "Drug-induced peripheral neuropathies." Br Med J 1 (1979): 663-6

Carrion C, Espinosa E, Herrero A, Garcia B "Possible vincristine-isoniazid interaction." Ann

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Chin RL "Laxative-induced hypokalemia." Ann Emerg Med 32 (1998): 517-8

Blumenthal M, Goldberg A, Brinckmann J, eds. "Herbal Medicine: Expanded Commission E

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GENERALLY AVOID: Butyrophenone neuroleptics may antagonize the pharmacologic

Reid AA "Pharmacological antagonism between chlorpromazine and phenmetrazine in mental hospital

"Product Information. Vyvanse (lisdexamfetamine)." Shire US Inc, Florence, KY.

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Serum concentrations of isoniazid may be reduced and corticosteroid levels may be