COMMON DRUG INTERACTIONS IN PRACTICE

WHY are drug interactions important?

HOW are drug interactions caused?
Potential to cause significant harm
Drug dosing
Drug-disease
Large number of drugs are introduced every
Timing
Drug-food
year
Side effect profile
Absorption
Useful for guided directed therapy
CYP450 pathway
Some drugs have a narrow therapeutic index
HOW can drug interactions be avoided?
Change medication
Change administration timing
Change dose
Frequent monitoring
WHAT are the common drug interactions?
Cytochrome P450**
CYP2C8

General
Inducers
Offenders
(inhibitors)

Gemfibrozil

Victims

amiodarone,
NSAIDs,
Warfarin

Solution

Fenofibrate

Side Effect
Solution

CYP2D6
CYP3A4
CYP2C9
CYP1A2
Carbamazepine, Phenytoin, Rifampin
**Always run drug interactions with these medications**
Paroxetine,
Antifungals,
Antifungals,
Ciprofloxacin,
Fluoxetine,
Macrolides,
SSRIs (fluoxetine/ Fluvoxamine,
fluvoxamine/
Bupropion
Amlodipine
Oral
sertraline),
Contraceptives
Amiodarone
Beta-Blockers,
PPIs, steroids,
NSAIDs,
Propranolol
antidepressants,
statins, CCBs,
sulfonylureas,
antipsychotics
sleep aids
carvedilol
(zolpidem,
Benadryl)
Sertraline,
Terbinafine
Avoid
Alternative
Citalopram,
OR
combinations
beta-blocker
Venlafaxine,
Change statin
Escitalopram
do not exceed simvastatin 20mg with amlodipine
Drug-Drug Interactions*

Viagra &
Nitrates

SSRIs & Linezolid

Statins & Fibrates

blood
pressure
Avoid
concomitant use

Increased risk of
serotonin syndrome
Avoid combination &
wait 2 weeks after SSRI
d/c to initiate linezolid

risk of myopathy

ACEI &
Spironolactone,
K+ supplements
K+ levels

Use caution and

frequent monitoring

Use caution and

frequent monitoring

Drug-Drug Interactions*
Sucralfate

Digoxin & macrolide/

azoles

Side Effect

absorption of
medications

digoxin elimination

Solution

Separate doses
(generally 2h
before and 4h
after)

Use cephs, pens, FQs/

voriconazole,
terbinafine

Problem

Solution

Warfarin & FAB4

Quinolones &
Amiodarone

(Flagyl, Amiodarone,
Bactrim, Fluconazole)

warfarin
concentration &
bleed risk
Avoid concomitant
use

Drug-Disease Interactions*
(Overlapping ADRs, absorption, etc.)
NSAIDs
Steroids
Beta-blockers DM
HF, HTN
HTN, DM
NSAIDs & fluid
blood pressure Hypoglycemia symptoms
retention results
by volume
masked
in HF exacerbation
expansion;
and BP
blood glucose
Avoid NSAIDs,
Short course
Ensure proper
consider APAP
therapy and close
counseling and refer to
monitoring
pharmacy

QT prolongation

Identify at risk
patients- avoid &
monitor patients.
Consider alternative
ABX

Diuretics (loops,
thiazides) Gout
Cause uric acid
retention

Use alternative
diuretics or
alternate BP agent

Drug-Food Interactions*

Problem

Solution

Warfarin
Vitamin K
bleeding
risk

Statin
Grapefruit juice
myopathy risk

Levothyroxine
Food
Prevents
absorption

Diabetic agents
alcohol
Risk of
hypoglycemia

Monitor INR,
eat consistent
amount of
vitamin K
weekly

Avoid grapefruit
juice or switch to
pravastatin for
moderate
intensity
alternative

Take
medication on
empty
stomach; 30
minutes
before meals

Avoid
combination of
medication with
alcohol

Antibiotics
dairy products
Prevents
absorption of
tetracyclines
and FQ
Separate use by
2h before and
4h after

HOW can drug interactions be avoided??

Contact your pharmacist with any drug related questions or problems!!
Let us help you with medication reconciliation and counseling
**Not an all-inclusive list. List associated with strong interactions.
*All interactions pertinent to IM clinical practice & associated with the most common/preventable interactions