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Drug Interactions between M-Clear WC and st. john's wort

This report displays the potential drug interactions for the following 2 drugs:

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Interactions between your drugs

Moderate

codeine St. John's wort

Applies to: M-Clear WC (codeine / guaifenesin) and st. john's wort

MONITOR: Coadministration of codeine or dihydrocodeine with CYP450 3A4 inducers such as St. John's Wort may result in lower codeine or dihydrocodeine plasma concentrations, higher levels of the inactive metabolite norcodeine or dihydronorcodeine, and less metabolism via CYP450 2D6, resulting in lower morphine or dihydromorphine levels, respectively. This interaction may lead to reduced codeine or dihydrocodeine efficacy and potentially initiate the onset of withdrawal symptoms in patients who are physically dependent. In addition, patients may be at an increased risk of CNS and/or respiratory-depressant effects from increased levels of codeine or dihydrocodeine once concomitant therapy with the CYP450 3A4 inducer is ceased. Also, opioids may potentiate the serotonergic effects and CNS depressant effects of St. John's Wort and increase the risk of serotonin syndrome. The potential for serotonin syndrome has primarily been reported with the phenylpiperidine opioids (e.g., meperidine, fentanyl) and tramadol, which are known to possess some serotonergic activity, although a few cases have involved other opioids such as codeine.

MANAGEMENT: Caution and clinical monitoring are advised if codeine or dihydrocodeine are to be used in combination with St. John's Wort, particularly when it is added to or withdrawn from therapy. Dosage adjustments may be required. Some manufacturers of products containing codeine recommend against using codeine concomitantly with CYP450 3A4 inducers. Patients should be advised to monitor for symptoms of serotonin excess or serotonin syndrome. If serotonin syndrome develops or is suspected during the course of therapy, all serotonergic agents should be discontinued immediately, and supportive care rendered as necessary. Patients should also be advised to avoid hazardous activities requiring complete mental alertness and motor coordination until they know how these medications affect them.

References

  1. Cerner Multum, Inc. "UK Summary of Product Characteristics." O 0
  2. Cerner Multum, Inc. "Australian Product Information." O 0
  3. "Product Information. Codeine Sulfate (codeine)." Lannett Company Inc (2015):
  4. "Product Information. Acetaminophen-Codeine Phosphate (acetaminophen-codeine)." Qualitest Products Inc (2015):
  5. Cerner Multum, Inc. "Canadian Product Information." O 0 (2015):
  6. "Product Information. Trezix (acetaminophen/caffeine/dihydrocodeine)." WraSer Pharmaceuticals (2016):
  7. "Product Information. Tuzistra XR (chlorpheniramine-codeine)." Vernalis Pharmaceuticals Inc (2016):
  8. Caraco Y, Sheller J, Wood AJ "Pharmacogenetic determinants of codeine induction by rifampin: the impact on codeine's respiratory, psychomotor and miotic effects." J Pharmacol Exp Ther 281 (1997): 330-6
  9. "Product Information. Dvorah (acetaminophen/caffeine/dihydrocodeine)." Skylar Laboratories (2020):
View all 9 references

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Drug and food interactions

Moderate

St. John's wort food

Applies to: st. john's wort

GENERALLY AVOID: An isolated case report suggests that foods containing large amounts of tyramine may precipitate a hypertensive crisis in patients treated with St. John's wort. The mechanism of interaction is unknown, as St. John's wort is not thought to possess monoamine oxidase (MAO) inhibiting activity at concentrations achieved in vivo. The case patient was a 41-year-old man who had been taking St. John's wort for seven days prior to presentation at the emergency room with confusion and disorientation. The patient recalled last eating aged cheese and having a glass of red wine approximately 10 hours prior to admission. No other cause of delirium or hypertension could be identified. In addition, alcohol may potentiate some of the pharmacologic effects of St. John's wort. Use in combination may result in additive central nervous system depression and/or impairment of judgment, thinking, and psychomotor skills.

MANAGEMENT: Until further information is available, patients treated with St. John's wort should consider avoiding consumption of protein foods in which aging or breakdown of protein is used to increase flavor. These foods include cheese (particularly strong, aged or processed cheeses), sour cream, wine (particularly red wine), champagne, beer, pickled herring, anchovies, caviar, shrimp paste, liver (particularly chicken liver), dry sausage, figs, raisins, bananas, avocados, chocolate, soy sauce, bean curd, yogurt, papaya products, meat tenderizers, fava beans, protein extracts, and dietary supplements. Caffeine may also precipitate hypertensive crisis so its intake should be minimized as well. Patients should also be advised to avoid or limit consumption of alcohol.

References

  1. Patel S, Robinson R, Burk M "Hypertensive crisis associated with St. John's Wort." Am J Med 112 (2002): 507-8

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Moderate

codeine food

Applies to: M-Clear WC (codeine / guaifenesin)

GENERALLY AVOID: Ethanol may potentiate the central nervous system (CNS) depressant effects of opioid analgesics. Concomitant use may result in additive CNS depression and impairment of judgment, thinking, and psychomotor skills. In more severe cases, hypotension, respiratory depression, profound sedation, coma, or even death may occur.

MANAGEMENT: Concomitant use of opioid analgesics with ethanol should be avoided.

References

  1. Linnoila M, Hakkinen S "Effects of diazepam and codeine, alone and in combination with alcohol, on simulated driving." Clin Pharmacol Ther 15 (1974): 368-73
  2. Sturner WQ, Garriott JC "Deaths involving propoxyphene: a study of 41 cases over a two-year period." JAMA 223 (1973): 1125-30
  3. Girre C, Hirschhorn M, Bertaux L, et al. "Enhancement of propoxyphene bioavailability by ethanol: relation to psychomotor and cognitive function in healthy volunteers." Eur J Clin Pharmacol 41 (1991): 147-52
  4. Levine B, Saady J, Fierro M, Valentour J "A hydromorphone and ethanol fatality." J Forensic Sci 29 (1984): 655-9
  5. Sellers EM, Hamilton CA, Kaplan HL, Degani NC, Foltz RL "Pharmacokinetic interaction of propoxyphene with ethanol." Br J Clin Pharmacol 19 (1985): 398-401
  6. Carson DJ "Fatal dextropropoxyphene poisoning in Northern Ireland. Review of 30 cases." Lancet 1 (1977): 894-7
  7. Rosser WW "The interaction of propoxyphene with other drugs." Can Med Assoc J 122 (1980): 149-50
  8. Edwards C, Gard PR, Handley SL, Hunter M, Whittington RM "Distalgesic and ethanol-impaired function." Lancet 2 (1982): 384
  9. Kiplinger GF, Sokol G, Rodda BE "Effect of combined alcohol and propoxyphene on human performance." Arch Int Pharmacodyn Ther 212 (1974): 175-80
View all 9 references

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Therapeutic duplication warnings

No warnings were found for your selected drugs.

Therapeutic duplication warnings are only returned when drugs within the same group exceed the recommended therapeutic duplication maximum.

See also

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Drug Interaction Classification

These classifications are only a guideline. The relevance of a particular drug interaction to a specific individual is difficult to determine. Always consult your healthcare provider before starting or stopping any medication.
Major Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit.
Moderate Moderately clinically significant. Usually avoid combinations; use it only under special circumstances.
Minor Minimally clinically significant. Minimize risk; assess risk and consider an alternative drug, take steps to circumvent the interaction risk and/or institute a monitoring plan.
Unknown No interaction information available.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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