Drug Interactions between Anoro Ellipta and aripiprazole

MONITOR: It is uncertain whether aripiprazole causes clinically significant prolongation of the QT interval. In clinical trials with aripiprazole involving patients with schizophrenia or bipolar mania, the incidence of QT prolongation was comparable to placebo. In postmarketing experience, QT prolongation, sudden death, torsade de pointes, ventricular tachycardia, arrhythmia, and cardiopulmonary arrest have been reported. However, these events were very rare or isolated, and many of the patients had preexisting cardiovascular disease, were on concomitant medications known to prolong the QT interval, had risk factors for QT prolongation, took an overdose of aripiprazole, and/or were morbidly obese. On the contrary, most data available in the medical literature suggest that aripiprazole either has no effect on the QT interval, or it may even cause a slight shortening of the QT interval within the dosage range of 10 to 30 mg/day.

MANAGEMENT: Some authorities recommend caution when aripiprazole is used with drugs that are known to cause QT prolongation. ECG monitoring may be advisable in some cases, such as in patients with a history of cardiac arrhythmias or congenital or family history of long QT syndrome. 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.

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GENERALLY AVOID: The potential exists for additive anticholinergic effects such as mydriasis, blurred vision, heat intolerance, fever, dry mouth, tachycardia, urinary retention, constipation, and glaucoma (onset or exacerbation) when topical or inhaled anticholinergic agents are used with each other or with other agents that possess anticholinergic properties. The risk of systemic anticholinergic effects following topical administration depends on variables such as strength of the product, size of the application area, frequency of application, and use of occlusive dressing. Systemic effects are uncommon following oral inhalation or nasal administration due to the poor absorption of quaternary ammonium compounds from gastrointestinal and nasal mucosa. However, worsening of urinary retention or angle-closure glaucoma has been reported with the use of orally inhaled anticholinergic agents. Increased intraocular pressure and precipitation or exacerbation of angle-closure glaucoma may also occur due to inadvertent contact of the eye with aerosolized or nebulized drug.

MANAGEMENT: Topical and inhaled anticholinergic preparations should preferably not be used in combination with other anticholinergic agents or agents with significant anticholinergic effects such as antihistamines, antispasmodics, neuroleptics, phenothiazines, skeletal muscle relaxants, tricyclic antidepressants, and class IA antiarrhythmics (especially disopyramide). Caution is advised if concomitant use cannot be avoided, particularly in the elderly and those with significantly impaired renal and/or hepatic function. Measures should be taken whenever possible to minimize ocular exposure to these drugs, such as keeping eyes closed during oral inhalation, use of a mouthpiece rather than face mask during nebulization, and not touching the eyes following topical application until hands are washed with soap and water. Patients should be advised to contact their physician if they experience excessive anticholinergic adverse effects or signs and symptoms of angle-closure glaucoma (e.g., eye pain or discomfort; blurred vision; visual halos; colored images in association with red eyes from conjunctival congestion or corneal edema).

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