According to the manufacturer of asenapine, the drug should be avoided in combination with other agents also known to have this effect. Atenolol: Moderate Use of a betaselective cardioselective beta blocker is recommended whenever possible when this combination of drugs must be used together. Atenolol; Chlorthalidone: Moderate Use of a betaselective cardioselective beta blocker is recommended whenever possible when this combination of drugs must be used together.
Atomoxetine: Minor Use caution when using atomoxetine in combination with short-acting beta-agonists as concurrent use may increase the risk of QT prolongation. QT prolongation has occurred during therapeutic use of atomoxetine and following overdose. This risk may be more clinically significant with long-acting beta-agonistsas compared to short-acting beta-agonists.
Azithromycin: Major Avoid coadministration of azithromycin with short-acting beta-agonists due to the increased risk of QT prolongation. If use together is necessary, obtain an ECG at baseline to assess initial QT interval and determine frequency of subsequent ECG monitoring, avoid any non-essential QT prolonging drugs, and correct electrolyte imbalances.
QT prolongation and torsade de pointes TdP have been spontaneously reported during azithromycin postmarketing surveillance. This risk may be more clinically significant with long-acting beta-agonists as compared to short-acting beta-agonists. Bedaquiline: Minor Due to the potential for QT prolongation and torsade de pointes TdP , caution is advised when administering bedaquiline with beta-agonists.
Bedaquiline has been reported to prolong the QT interval. Prior to initiating bedaquiline, obtain serum electrolyte concentrations and a baseline ECG. An ECG should also be performed at least 2, 12, and 24 weeks after starting bedaquiline therapy.
Bendroflumethiazide; Nadolol: Moderate Use of a betaselective cardioselective beta blocker is recommended whenever possible when this combination of drugs must be used together. Benzphetamine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Beta-adrenergic blockers: Moderate Use of a betaselective cardioselective beta blocker is recommended whenever possible when this combination of drugs must be used together.
Betaxolol: Moderate Use of a betaselective cardioselective beta blocker is recommended whenever possible when this combination of drugs must be used together. Bisoprolol; Hydrochlorothiazide, HCTZ: Moderate Use of a betaselective cardioselective beta blocker is recommended whenever possible when this combination of drugs must be used together.
Brimonidine; Timolol: Moderate Use of a betaselective cardioselective beta blocker is recommended whenever possible when this combination of drugs must be used together. Brompheniramine; Carbetapentane; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Brompheniramine; Dextromethorphan; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Brompheniramine; Hydrocodone; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Brompheniramine; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Brompheniramine; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Brompheniramine; Pseudoephedrine; Dextromethorphan: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Bumetanide: Moderate Loop diuretics may potentiate hypokalemia and ECG changes seen with beta agonists. Hypokalemia due to beta agonists appears to be dose related and is more likely with high dose therapy. Caution is advised when loop diuretics are coadministered with high doses of beta agonists; potassium levels may need to be monitored. Buprenorphine: Minor Buprenorphine has been associated with QT prolongation and has a possible risk of torsade de pointes TdP. FDA-approved labeling for some buprenorphine products recommend avoiding use with Class 1A and Class III antiarrhythmic medications while other labels recommend avoiding use with any drug that has the potential to prolong the QT interval.
Buprenorphine; Naloxone: Minor Buprenorphine has been associated with QT prolongation and has a possible risk of torsade de pointes TdP. Butalbital; Acetaminophen; Caffeine: Moderate Caffeine may enhance the cardiac inotropic effects of beta-agonists. Butalbital; Acetaminophen; Caffeine; Codeine: Moderate Caffeine may enhance the cardiac inotropic effects of beta-agonists. Cabotegravir; Rilpivirine: Minor Caution is advised when administering rilpivirine with short-acting beta-agonists as concurrent use may increase the risk of QT prolongation.
Caffeine: Moderate Caffeine may enhance the cardiac inotropic effects of beta-agonists. Caffeine; Sodium Benzoate: Moderate Caffeine may enhance the cardiac inotropic effects of beta-agonists.
Carbetapentane; Chlorpheniramine; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Carbetapentane; Diphenhydramine; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Carbetapentane; Guaifenesin; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Carbetapentane; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Carbetapentane; Phenylephrine; Pyrilamine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Carbetapentane; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Carbinoxamine; Dextromethorphan; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Carbinoxamine; Hydrocodone; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Carbinoxamine; Hydrocodone; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Carbinoxamine; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Carbinoxamine; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Carbonic anhydrase inhibitors: Moderate Albuterol may cause additive hypokalemia when coadministered with carbonic anhydrase inhibitors. Carteolol: Moderate Use of a betaselective cardioselective beta blocker is recommended whenever possible when this combination of drugs must be used together.
Carvedilol: Moderate Use of a betaselective cardioselective beta blocker is recommended whenever possible when this combination of drugs must be used together. Ceritinib: Minor Periodically monitor electrolytes and ECGs in patients receiving concomitant treatment with ceritinib and long-acting beta-agonists; an interruption of ceritinib therapy, dose reduction, or discontinuation of therapy may be necessary if QT prolongation occurs.
Ceritinib causes concentration-dependent prolongation of the QT interval. Cetirizine; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Chlophedianol; Dexchlorpheniramine; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Chlophedianol; Guaifenesin; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Chlordiazepoxide; Amitriptyline: Minor Tricyclic antidepressants TCAs share pharmacologic properties similar to the Class IA antiarrhythmic agents and may prolong the QT interval, particularly in overdose or with higher-dose prescription therapy elevated serum concentrations.
Chloroquine: Major Avoid coadministration of chloroquine with short-acting beta-agonists due to the increased risk of QT prolongation. Chloroquine is associated with an increased risk of QT prolongation and torsade de pointes TdP ; the risk of QT prolongation is increased with higher chloroquine doses.
Chlorpheniramine; Dextromethorphan; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Chlorpheniramine; Dextromethorphan; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Chlorpheniramine; Dihydrocodeine; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Chlorpheniramine; Dihydrocodeine; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Chlorpheniramine; Guaifenesin; Hydrocodone; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Chlorpheniramine; Hydrocodone; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Chlorpheniramine; Hydrocodone; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Chlorpheniramine; Ibuprofen; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Chlorpheniramine; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Chlorpheniramine; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
This risk is generally higher at elevated drugs concentrations of phenothiazines. Chlorpromazine is specifically associated with an established risk of QT prolongation and TdP; case reports have included patients receiving therapeutic doses of chlorpromazine. Agents that prolong the QT interval could lead to torsade de pointes when combined with a phenothiazine, and therefore are generally not recommended for combined use.
Drugs with a possible risk for QT prolongation and TdP that should be used cautiously and with close monitoring with chlorpromazine include the beta-agonists. Ciprofloxacin: Minor Rare cases of QT prolongation and torsade de pointe TdP have been reported with ciprofloxacin during post-marketing surveillance. Ciprofloxacin should be used with caution in patients receiving drugs that prolong the QT interval. Drugs with a possible risk for QT prolongation and TdP that should be used cautiously with ciprofloxacin include the beta-agonists.
Cisapride: Contraindicated QT prolongation and ventricular arrhythmias, including torsade de pointes TdP and death, have been reported with cisapride.
Because of the potential for TdP, use of other drugs that might increase the QT interval is contraindicated with cisapride. Citalopram: Minor Citalopram causes dose-dependent QT interval prolongation. According to the manufacturer, concurrent use of citalopram with other drugs that prolong the QT interval is not recommended. If concurrent therapy is considered essential, ECG monitoring is recommended. Drugs with a possible risk for QT prolongation and TdP that should be used cautiously and with close monitoring with citalopram include the beta-agonists.
Clarithromycin: Minor The coadministration of beta-agonists with clarithromycin may increase the risk for adverse effects, including prolongation of the QT interval. QT prolongation and torsade de pointes have been reported in patients receiving clofazimine in combination with QT prolonging medications.
Clomipramine: Minor Tricyclic antidepressants TCAs share pharmacologic properties similar to the Class IA antiarrhythmic agents and may prolong the QT interval, particularly in overdose or with higher-dose prescription therapy elevated serum concentrations. Clozapine: Minor Treatment with clozapine has been associated with QT prolongation, torsade de pointes TdP , cardiac arrest, and sudden death.
The manufacturer of clozapine recommends caution during concurrent use with medications known to cause QT prolongation. Drugs with a possible risk for QT prolongation that should be used cautiously and with close monitoring with clozapine include the beta-agonists. Cocaine: Moderate Additive effects and increased toxicity might be observed when using cocaine with beta-agonists, which are sympathomimetic agents.
The combined use of these agents may have the potential for additive adrenergic stimulation and side effects, such as nervousness, insomnia, palpitations, or adverse cardiovascular effects.
Codeine; Guaifenesin; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Codeine; Phenylephrine; Promethazine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Use cautiously with promethazine, which has been reported to cause QT prolongation. Crizotinib: Minor Monitor ECGs for QT prolongation and monitor electrolytes in patients receiving crizotinib concomitantly with short-acting beta-agonists. An interruption of therapy, dose reduction, or discontinuation of therapy may be necessary for crizotinib patients if QT prolongation occurs. Crizotinib has been associated with concentration-dependent QT prolongation. Dasatinib: Minor Use dasatinib with caution in combination with beta-agonists as concurrent use may increase the risk of QT prolongation.
In vitro studies have shown that dasatinib has the potential to prolong the QT interval. Degarelix: Minor Consider whether the benefits of androgen deprivation therapy outweigh the potential risks in patients receiving short-acting beta-agonists as concurrent use may increase the risk of QT prolongation. Androgen deprivation therapy i. Desipramine: Minor Tricyclic antidepressants TCAs share pharmacologic properties similar to the Class IA antiarrhythmic agents and may prolong the QT interval, particularly in overdose or with higher-dose prescription therapy elevated serum concentrations.
Desloratadine; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Deutetrabenazine: Minor The risk of QT prolongation may be increased with coadministration of deutetrabenazine and short-acting beta-agonists. Deutetrabenazine may prolong the QT interval, but the degree of QT prolongation is not clinically significant when deutetrabenazine is administered within the recommended dosage range.
Dexbrompheniramine; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Dexchlorpheniramine; Dextromethorphan; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Dextroamphetamine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Dextromethorphan; Diphenhydramine; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Dextromethorphan; Guaifenesin; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Dextromethorphan; Guaifenesin; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Dextromethorphan; Quinidine: Minor Beta-agonists should be used cautiously with quinidine. Quinidine administration is associated with QT prolongation and torsades de pointes TdP.
Beta-agonists should be administered with extreme caution to patients being treated with drugs known to prolong the QT interval because the action of beta-agonists on the cardiovascular system may be potentiated.
Dichlorphenamide: Moderate Use dichlorphenamide and albuterol together with caution. Metabolic acidosis has been reported with dichlorphenamide and albuterol aerosol and inhalation solution. Concurrent use may increase the severity of metabolic acidosis. Measure sodium bicarbonate concentrations at baseline and periodically during dichlorphenamide treatment. If metabolic acidosis occurs or persists, consider reducing the dose or discontinuing dichlorphenamide therapy.
Diethylpropion: Major Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
The clinical significance of these findings for patients with obstructive airway disease who are receiving albuterol or levalbuterol and digoxin on a chronic basis is unclear. The manufacturer of digoxin recommends measuring serum digoxin concentrations prior to initiation of albuterol or levalbuterol.
Dihydrocodeine; Guaifenesin; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Diphenhydramine; Hydrocodone; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Diphenhydramine; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Disopyramide: Minor Beta-agonists should be used cautiously and with close monitoring with disopyramide. Disopyramide administration is associated with QT prolongation and torsade de pointes TdP. Dobutamine: Major Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Dofetilide: Minor Coadministration of dofetilide and short-acting beta-agonists may increase the risk of QT prolongation.
Dolasetron: Minor Administer dolasetron with caution in combination with short-acting beta-agonists as concurrent use may increase the risk of QT prolongation. Dolutegravir; Rilpivirine: Minor Caution is advised when administering rilpivirine with short-acting beta-agonists as concurrent use may increase the risk of QT prolongation. Donepezil: Minor Use donepezil with caution in combination with short-acting beta-agonists as concurrent use may increase the risk of QT prolongation.
Case reports indicate that QT prolongation and torsade de pointes TdP can occur during donepezil therapy. Donepezil; Memantine: Minor Use donepezil with caution in combination with short-acting beta-agonists as concurrent use may increase the risk of QT prolongation. Dopamine: Major Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Dorzolamide; Timolol: Moderate Use of a betaselective cardioselective beta blocker is recommended whenever possible when this combination of drugs must be used together.
Doxapram: Major Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Doxepin: Minor Tricyclic antidepressants TCAs share pharmacologic properties similar to the Class IA antiarrhythmic agents and may prolong the QT interval, particularly in overdose or with higher-dose prescription therapy elevated serum concentrations.
Dronedarone: Contraindicated Dronedarone administration is associated with a dose-related increase in the QTc interval. The increase in QTc is approximately 10 milliseconds at doses of mg twice daily the FDA-approved dose and up to 25 milliseconds at doses of mg twice daily. Although there are no studies examining the effects of dronedarone in patients receiving other QT prolonging drugs, coadministration of such drugs may result in additive QT prolongation.
The concomitant use of dronedarone with other drugs that prolong the QTc may induce Torsade de Pointes TdP and is contraindicated. Contraindicated drugs include the beta-agonists. Droperidol: Minor Droperidol should be administered with extreme caution to patients receiving other agents that may prolong the QT interval. Droperidol administration is associated with an established risk for QT prolongation and torsade de pointes TdP.
In December , the FDA issued a black box warning regarding the use of droperidol and its association with QT prolongation and potential for cardiac arrhythmias based on post-marketing surveillance data. According to the revised labeling for droperidol, any drug known to have potential to prolong the QT interval should not be coadministered with droperidol.
Drugs with a possible risk for QT prolongation that should be used cautiously and with close monitoring with droperidol include beta-agonists. Efavirenz: Minor Consider alternatives to efavirenz when coadministering with short-acting beta-agonists.
QTc prolongation has been observed with the use of efavirenz. Beta-agonists may also be associated with adverse cardiovascular effects including QT interval prolongation, usually at higher doses, when associated with hypokalemia, or when used with other drugs known to prolong the QT interval.
Efavirenz; Emtricitabine; Tenofovir: Minor Consider alternatives to efavirenz when coadministering with short-acting beta-agonists. Efavirenz; Lamivudine; Tenofovir Disoproxil Fumarate: Minor Consider alternatives to efavirenz when coadministering with short-acting beta-agonists.
Drugs with a possible risk for QT prolongation and torsade de pointes TdP that should be used cautiously and with close monitoring with eliglustat include beta-agonists.
Emtricitabine; Rilpivirine; Tenofovir alafenamide: Minor Caution is advised when administering rilpivirine with short-acting beta-agonists as concurrent use may increase the risk of QT prolongation.
Emtricitabine; Rilpivirine; Tenofovir disoproxil fumarate: Minor Caution is advised when administering rilpivirine with short-acting beta-agonists as concurrent use may increase the risk of QT prolongation. Encorafenib: Minor If encorafenib is coadministered with a short-acting beta-agonist, consider monitoring ECGs for QT prolongation and monitor electrolytes; correct hypokalemia and hypomagnesemia prior to treatment. Encorafenib is associated with dose-dependent prolongation of the QT interval.
Enflurane: Minor Enflurane, like other halogenated anesthetics, can prolong the QT interval. Drugs with a possible risk for QT prolongation that should be used cautiously with halogenated anesthetics include the beta-agonists. The action of beta-agonists on the cardiovascular system may be potentiated by a halogenated anesthetic. Entrectinib: Minor Coadministration of entrectinib and short-acting beta-agonists may increase the risk of QT prolongation.
Entrectinib has been associated with QT prolongation. Ephedrine: Major Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Ephedrine; Guaifenesin: Major Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Epinephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Ergotamine; Caffeine: Moderate Caffeine may enhance the cardiac inotropic effects of beta-agonists. Eribulin: Minor Eribulin has been associated with QT prolongation. If eribulin and another drug that prolongs the QT interval must be coadministered, ECG monitoring is recommended; closely monitor the patient.
Drugs with a possible risk for QT prolongation and TdP that should be used cautiously and with close monitoring with erythromycin include the beta-agonists. The effects of these beta-agonists on the cardiovascular system may be potentiated. Escitalopram: Minor Use escitalopram with caution in combination with short-acting beta agonists as concurrent use may increase the risk of QT prolongation. Escitalopram has been associated with a risk of QT prolongation and torsade de pointes TdP. Beta-agonists may be associated with adverse cardiovascular effects including QT interval prolongation, usually at higher doses, when associated with hypokalemia, or when used with escitalopram.
Esmolol: Moderate Use of a betaselective cardioselective beta blocker is recommended whenever possible when this combination of drugs must be used together. Ezogabine: Minor Use caution during concurrent use of ezogabine and short-acting beta-agonists as concurrent use may increase the risk of QT prolongation.
Ezogabine has been associated with QT prolongation. Fexofenadine; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Fingolimod: Minor Fingolimod initiation results in decreased heart rate and the drug may prolong the QT interval. After the first fingolimod dose, overnight monitoring with continuous ECG in a medical facility is advised for patients taking QT prolonging drugs with a known risk of torsade de pointes TdP. Fingolimod has not been studied in patients treated with drugs that prolong the QT interval, however, drugs that prolong the QT interval have been associated with cases of TdP in patients with bradycardia.
Drugs with a possible risk for QT prolongation that should be used cautiously and with close monitoring with fingolimod include the beta-agonists. Although causality for TdP has not been established for flecainide, patients receiving concurrent drugs which have the potential for QT prolongation may have an increased risk of developing proarrhythmias.
Drugs with a possible risk for QT prolongation and TdP that should be used cautiously with flecainide include the beta-agonists.
Fluconazole: Minor Use fluconazole with caution in combination with beta-agonists as concurrent use may increase the risk of QT prolongation. Fluconazole has been associated with QT prolongation and rare cases of torsade de pointes TdP.
Fluoxetine: Minor Use fluoxetine with caution in combination with short-acting beta-agonists. Coadministration may increase the risk for QT prolongation and torsade de pointes TdP. QT prolongation and TdP have been reported in patients treated with fluoxetine. Fluphenazine: Minor Fluphenazine, a phenothiazine, is associated with a possible risk for QT prolongation.
Drugs with a possible risk for QT prolongation and TdP that should be used cautiously with fluphenazine include the beta-agonists. Fluvoxamine: Minor There may be an increased risk for QT prolongation and torsade de pointes TdP during concurrent use of fluvoxamine and short-acting beta-agonists. Coadminister with caution. QT prolongation and TdP have been reported during postmarketing use of fluvoxamine. This risk may be more clinically significant with long-acting beta-agonists compared to short-acting beta-agonists.
Foscarnet: Major When possible, avoid concurrent use of foscarnet with other drugs known to prolong the QT interval, such as short-acting beta-agonists. Foscarnet has been associated with postmarketing reports of both QT prolongation and torsade de pointes TdP.
If these drugs are administered together, obtain an electrocardiogram and electrolyte concentrations before and periodically during treatment. Fostemsavir: Minor Use beta-agonists and fostemsavir together with caution due to the potential for QT prolongation. Supratherapeutic doses of fostemsavir 2, mg twice daily, four times the recommended daily dose have been shown to cause QT prolongation.
Fostemsavir causes dose-dependent QT prolongation. Furosemide: Moderate Loop diuretics may potentiate hypokalemia and ECG changes seen with beta agonists.
Gemifloxacin: Minor Use gemifloxacin and short-acting beta-agonists together with caution due to increased risk for QT prolongation and torsade de pointes TdP. Gemifloxacin may prolong the QT interval in some patients. The maximal change in the QTc interval occurs approximately 5 to 10 hours following oral administration of gemifloxacin.
The likelihood of QTc prolongation may increase with increasing dose of the drug; therefore, the recommended dose should not be exceeded especially in patients with renal or hepatic impairment where the Cmax and AUC are slightly higher.
Gemtuzumab Ozogamicin: Minor Coadministration of gemtuzumab ozogamicin with short-acting beta-agonists may increase the potential for additive QT prolongation and risk of torsade de pointes TdP. Although QT interval prolongation has not been reported with gemtuzumab, it has been reported with other drugs that contain calicheamicin. Gilteritinib: Minor Use caution and monitor for additive QT prolongation if concurrent use of gilteritinib and a short-acting beta-agonist is necessary.
Gilteritinib has been associated with QT prolongation. Glasdegib: Minor Consider increased frequency of ECG monitoring if coadministration of glasdegib and short-acting beta-agonists is necessary. Glasdegib therapy may result in QT prolongation and ventricular arrhythmias including ventricular fibrillation and ventricular tachycardia. Goserelin: Minor Consider whether the benefits of androgen deprivation therapy i. Granisetron: Minor Use granisetron with caution in combination with short-acting beta-agonists due to the risk of QT prolongation.
Granisetron has been associated with QT prolongation. Additive effects are expected if used in combination with other CNS stimulants including the beta-agonists. Guaifenesin; Hydrocodone; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Guaifenesin; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects. Guaifenesin; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Halofantrine: Contraindicated Halofantrine is considered to have a well-established risk for QT prolongation and torsade de pointes TdP. Halofantrine should be avoided in patients receiving drugs which may induce QT prolongation. These drugs include the beta-agonists.
Haloperidol: Minor Caution is advisable when combining haloperidol concurrently with short-acting beta-agonists as concurrent use may increase the risk of QT prolongation. QT prolongation and torsade de pointes TdP have been observed during haloperidol treatment. Excessive doses particularly in the overdose setting or IV administration of haloperidol may be associated with a higher risk of QT prolongation.
Halothane: Minor Halothane, like other halogenated anesthetics, can prolong the QT interval. Histrelin: Minor Consider whether the benefits of androgen deprivation therapy i.
Hydrocodone; Phenylephrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Hydrocodone; Potassium Guaiacolsulfonate; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Hydrocodone; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Hydroxychloroquine: Major Avoid coadministration of short-acting beta-agonists and hydroxychloroquine due to an increased risk of QT prolongation. Hydroxychloroquine prolongs the QT interval. Hydroxyzine: Minor Caution is recommended if hydroxyzine is administered with short-acting beta-agonists due to the potential for additive QT prolongation and risk of torsade de pointes TdP. Postmarketing data indicate that hydroxyzine causes QT prolongation and TdP. Ibuprofen; Pseudoephedrine: Moderate Caution and close observation should be used when albuterol is used concurrently with other adrenergic sympathomimetics, administered by any route, to avoid potential for increased cardiovascular effects.
Administration of drugs by the sublingual route provides rapid systemic absorption and avoids first-pass metabolism. The purpose of the present study was to assess the pharmacokinetics, efficacy and adverse effects of standard salbutamol tablets given by this route to patients with asthma. Seven asthmatic patients were given either sublingual salbutamol tablet 2 mg SL , swallowed tablet 2 mg O , metered dose inhaler micrograms MDI or placebo PL , in a randomized single-blind cross-over design.
Therefore, when a weak acid is given orally, most of the drug in the stomach is un-ionized, favoring diffusion through the gastric mucosa. Theoretically, weakly acidic drugs eg, aspirin are more readily absorbed from an acid medium stomach than are weakly basic drugs eg, quinidine. Dosage forms eg, tablets, capsules, solutions , consisting of the drug plus Certain molecules with low lipid solubility eg, glucose penetrate membranes more rapidly than expected.
One theory is facilitated passive diffusion: A carrier molecule in the membrane combines reversibly with the substrate molecule outside the cell membrane, and the carrier-substrate complex diffuses rapidly across the membrane, releasing the substrate at the interior surface.
In such cases, the membrane transports only substrates with a relatively specific molecular configuration, and the availability of carriers limits the process. The process does not require energy expenditure, and transport against a concentration gradient cannot occur. Active transport is selective, requires energy expenditure, and may involve transport against a concentration gradient. Active transport seems to be limited to drugs structurally similar to endogenous substances eg, ions, vitamins, sugars, amino acids.
These drugs are usually absorbed from specific sites in the small intestine. In pinocytosis, fluid or particles are engulfed by a cell. The cell membrane invaginates, encloses the fluid or particles, then fuses again, forming a vesicle that later detaches and moves to the cell interior. Energy expenditure is required. Pinocytosis probably plays a small role in drug transport, except for protein drugs.
To be absorbed, a drug given orally must survive encounters with low pH and numerous gastrointestinal GI secretions, including potentially degrading enzymes. Peptide drugs eg, insulin are particularly susceptible to degradation and are not given orally. Absorption of oral drugs involves transport across membranes of the epithelial cells in the GI tract. Absorption is affected by. The oral mucosa has a thin epithelium and rich vascularity, which favor absorption; however, contact is usually too brief for substantial absorption.
A drug placed between the gums and cheek buccal administration or under the tongue sublingual administration is retained longer, enhancing absorption. Although the stomach has a relatively large epithelial surface, its thick mucous layer and short transit time limit drug absorption. These properties of the stomach can influence drug formulation and behavior.
Because most absorption occurs in the small intestine, gastric emptying is often the rate-limiting step. Food, especially fatty food, slows gastric emptying and rate of drug absorption , explaining why taking some drugs on an empty stomach speeds absorption.
Drugs that affect gastric emptying eg, parasympatholytic drugs affect the absorption rate of other drugs. Food may enhance the extent of absorption for poorly soluble drugs eg, griseofulvin , reduce it for drugs degraded in the stomach eg, penicillin G , or have little or no effect.
The small intestine has the largest surface area for drug absorption in the GI tract, and its membranes are more permeable than those in the stomach. The intraluminal pH is 4 to 5 in the duodenum but becomes progressively more alkaline, approaching 8 in the lower ileum. GI microflora may reduce absorption. Decreased blood flow eg, in shock may lower the concentration gradient across the intestinal mucosa and reduce absorption by passive diffusion.
Intestinal transit time can influence drug absorption, particularly for drugs that are absorbed by active transport eg, B vitamins , that dissolve slowly eg, griseofulvin , or that are polar ie, with low lipid solubility; eg, many antibiotics.
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