Mepergan Disease Interactions
There are 34 disease interactions with Mepergan (meperidine / promethazine).
- Impaired GI motility
- Infectious diarrhea
- Liver disease
- Prematurity
- Acute alcohol intoxication
- Drug dependence
- Gastrointestinal obstruction
- Hypotension
- Intracranial pressure
- Respiratory depression
- Acute alcohol intoxication
- Cardiovascular disease
- CNS depression
- Head injury
- Antidopaminergic effects 1
- Asthma
- Anticholinergic effects
- Asthma/COPD
- Adrenal insufficiency
- Biliary spasm
- Renal dysfunction
- Seizure disorders
- Urinary retention
- Arrhythmias
- Breast cancer
- Dystonic reactions
- Hematologic toxicity
- Liver disease
- NMS
- Parkinsonism
- Renal dysfunction
- Seizure disorders
- Tardive dyskinesia
- Antidopaminergic effects 2
Narcotic analgesics (applies to Mepergan) impaired GI motility
Major Potential Hazard, Moderate plausibility. Applicable conditions: Constipation, Gastrointestinal Obstruction, Inflammatory Bowel Disease, Intestinal Anastomoses
Narcotic (opioid) analgesic agents increase smooth muscle tone in the gastrointestinal tract and decrease peristalsis, which can lead to elevated intraluminal pressure, spasm, and constipation following prolonged use. In patients with severe or acute inflammatory bowel disease, the decrease in colonic motility may induce toxic megacolon. Therapy with opioids should be administered cautiously in patients with gastrointestinal obstruction, constipation, inflammatory bowel disease, or recent gastrointestinal tract surgery. Gastrointestinal effects appear to be the most pronounced with morphine.
References
- Kreek MJ, Hartman N "Chronic use of opioids and antipsychotic drugs: side effects, effects on endogenous opioids, and toxicity." Ann N Y Acad Sci 398 (1982): 151-72
- Bellville JW, Forrest WH, Elashoff J, Laska E "Evaluating side effects of analgesics in a cooperative clinical study." Clin Pharmacol Ther 9 (1968): 303-13
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. MS Contin (morphine)." Purdue Frederick Company PROD (2002):
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- White MJ, Berghausen EJ, Dumont SW, Tsueda K, Schroeder JA, Vogel RL, Heine MF, Huang KC "Side effects during continuous epidural infusion of morphine and fentanyl." Can J Anaesth 39 (1992): 576-82
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- Thorn SE, Wattwil M, Kallander A "Effects of epidural morphine and epidural bupivacaine on gastroduodenal motility during the fasted state and after food intake." Acta Anaesthesiol Scand 38 (1994): 57-62
- Bennett MWR, Shah MV, Bembridge JL "A comparison of the effect on gastric emptying of alfentanil or morphine given during anaesthesia for minor surgery." Anaesthesia 49 (1994): 155-6
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- "Product Information. Fentanyl Oralet (fentanyl)." Abbott Pharmaceutical, Abbott Park, IL.
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Stadol (butorphanol nasal)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Nubain (nalbuphine)." Endo Laboratories LLC PROD (2001):
- "Product Information. Buprenex (buprenorphine)." Reckitt and Colman Pharmaceuticals Inc PROD (2001):
- "Product Information. Talwin NX (pentazocine)." Sanofi Winthrop Pharmaceuticals PROD (2001):
- "Product Information. Stadol (butorphanol)." Allscrips Pharmaceutical Company PROD (2001):
- "Product Information. Dalgan (dezocine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
- "Product Information. Orlaam (levomethadyl acetate)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Nucynta (tapentadol)." PriCara Pharmaceuticals (2009):
Narcotic analgesics (applies to Mepergan) infectious diarrhea
Major Potential Hazard, Moderate plausibility. Applicable conditions: Infectious Diarrhea/Enterocolitis/Gastroenteritis
Narcotic (opioid) analgesic agents may prolong and/or worsen diarrhea associated with organisms that invade the intestinal mucosa, such as toxigenic E. coli, Salmonella, Shigella, and pseudomembranous colitis due to broad-spectrum antibiotics. These agents decrease gastrointestinal motility, which may delay the excretion of infective gastroenteric organisms and/or their toxins. Other symptoms and complications such as fever, shedding of organisms and extraintestinal illness may also be increased or prolonged. Therapy with opioids should be avoided or administered cautiously in patients with infectious diarrhea, particularly that due to pseudomembranous enterocolitis or enterotoxin-producing bacteria or if accompanied by high fever, pus, or blood in the stool.
References
- Kreek MJ, Hartman N "Chronic use of opioids and antipsychotic drugs: side effects, effects on endogenous opioids, and toxicity." Ann N Y Acad Sci 398 (1982): 151-72
- Bellville JW, Forrest WH, Elashoff J, Laska E "Evaluating side effects of analgesics in a cooperative clinical study." Clin Pharmacol Ther 9 (1968): 303-13
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. MS Contin (morphine)." Purdue Frederick Company PROD (2002):
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- White MJ, Berghausen EJ, Dumont SW, Tsueda K, Schroeder JA, Vogel RL, Heine MF, Huang KC "Side effects during continuous epidural infusion of morphine and fentanyl." Can J Anaesth 39 (1992): 576-82
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- Thorn SE, Wattwil M, Kallander A "Effects of epidural morphine and epidural bupivacaine on gastroduodenal motility during the fasted state and after food intake." Acta Anaesthesiol Scand 38 (1994): 57-62
- Bennett MWR, Shah MV, Bembridge JL "A comparison of the effect on gastric emptying of alfentanil or morphine given during anaesthesia for minor surgery." Anaesthesia 49 (1994): 155-6
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- "Product Information. Fentanyl Oralet (fentanyl)." Abbott Pharmaceutical, Abbott Park, IL.
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Stadol (butorphanol nasal)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Nubain (nalbuphine)." Endo Laboratories LLC PROD (2001):
- "Product Information. Buprenex (buprenorphine)." Reckitt and Colman Pharmaceuticals Inc PROD (2001):
- "Product Information. Talwin NX (pentazocine)." Sanofi Winthrop Pharmaceuticals PROD (2001):
- "Product Information. Stadol (butorphanol)." Allscrips Pharmaceutical Company PROD (2001):
- "Product Information. Dalgan (dezocine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
- "Product Information. Orlaam (levomethadyl acetate)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Nucynta (tapentadol)." PriCara Pharmaceuticals (2009):
Narcotic analgesics (applies to Mepergan) liver disease
Major Potential Hazard, High plausibility.
Narcotic (opioid) analgesic agents are extensively metabolized by the liver, and several of them (e.g., codeine, hydrocodone, meperidine, methadone, morphine, propoxyphene) have active metabolites that are further converted to inactive substances. The serum concentrations of these agents and their metabolites may be increased and the half-lives prolonged in patients with impaired hepatic function. Therapy with opioids should be administered cautiously and initiated at reduced dosages in patients with liver disease. Subsequent doses should be titrated based on individual response rather than a fixed dosing schedule.
References
- Yue QY, Hasselstrom J, Svensson JO, Sawe J "Pharmacokinetics of codeine and its metabolites in Caucasian healthy volunteers: comparisons between extensive and poor hydroxylators of debrisoquine." Br J Clin Pharmacol 31 (1991): 635-42
- Pond SM, Tong T, Benowitz NL, et al. "Presystemic metabolism of meperidine to normeperidine in normal and cirrhotic subjects." Clin Pharmacol Ther 30 (1981): 183-8
- Neal EA, Meffin PJ, Gregory PB, Blaschke TF "Enhanced bioavailability and decreased clearance of analgesics in patients with cirrhosis." Gastroenterology 77 (1979): 96-102
- Bower S, Sear JW, Roy RC, Carter RF "Effects of different hepatic pathologies on disposition of alfentanil in anaesthetized patients." Br J Anaesth 68 (1992): 462-5
- Parab PV, Ritschel WA, Coyle DE, et al. "Pharmacokinetics of hydromorphone after intravenous, peroral and rectal administration to human subjects." Biopharm Drug Dispos 9 (1988): 187-99
- Hill HF, Coda BA, Tanaka A, Schaffer R "Multiple-dose evaluation of intravenous hydromorphone pharmacokinetics in normal human subjects." Anesth Analg 72 (1991): 330-6
- Poyhia R, Seppala T, Olkkola KT, Kalso E "The pharmacokinetics and metabolism of oxycodone after intramuscular and oral administration to healthy subjects." Br J Clin Pharmacol 33 (1992): 617-21
- Mazoit J-X, Sandouk P, Zetlaoui P, Scherrmann J-M "Pharmacokinetics of unchanged morphine in normal and cirrhotic subjects." Anesth Analg 66 (1987): 293-8
- Poyhia R, Olkkola KT, Seppala T, Kalso E "The pharmacokinetics of oxycodone after intravenous injection in adults." Br J Clin Pharmacol 32 (1991): 516-8
- Osborne R, Joel S, Trew D, Slevin M "Morphine and metabolite behavior after different routes of morphine administration: demonstration of the importance of the active metabolite morphine-6-glucoronide." Clin Pharmacol Ther 47 (1990): 12-9
- Glare PA, Walsh TD "Clinical pharmacokinetics of morphine." Ther Drug Monit 13 (1991): 1-23
- Gram LF, Schou J, Way WL, et al. "delta-Propoxyphene kinetics after single oral and intravenous doses in man." Clin Pharmacol Ther 26 (1979): 473-82
- Yun CH, Wood M, Wood AJ, Guengerich FP "Identification of the pharmacogenetic determinants of alfentanil metabolism: cytochrome P-450 3A4: an explanation of the variable elimination clearance." Anesthesiology 77 (1992): 467-74
- Cone EJ, Darwin WD, Gorodetzky CW "Comparative metabolism of codeine in man, rat, dog, guinea-pig and rabbit: identification of four new metabolites." J Pharm Pharmacol 31 (1979): 314-7
- McHorse TS, Klotz U, Wilkinson G, Schenker S "Impaired elimination of meperidine in patients with liver disease." Trans Assoc Am Physicians 87 (1974): 281-7
- Hasselstrom J, Eriksson S, Persson A, Rane A, Svensson JO, Sawe J "The metabolism and bioavailability of morphine in patients with severe liver cirrhosis." Br J Clin Pharmacol 29 (1990): 289-97
- Novick DM, Kreek MJ, Arns PA, et al. "Effect of severe alcoholic liver disease on the disposition of methadone in maintenance patients." Alcohol Clin Exp Res 9 (1985): 349
- Kreek MJ, Fanizza AM, et al. "Methadone disposition in patients with chronic liver disease." Clin Pharmacol Ther 30 (1981): 353-62
- Leow KP, Smith MT, Williams B, Cramond T "Single-dose and steady-state pharmacokinetics and pharmacodynamics of oxycodone in patients with cancer." Clin Pharmacol Ther 52 (1992): 487-95
- Leow KP, Smith MT, Watt JA, Williams BE, Cramond T "Comparative oxycodone pharmacokinetics in humans after intravenous, oral, and rectal administration." Ther Drug Monit 14 (1992): 479-84
- Goromaru T, Matsuura H, Yoshimura N, Miyawaki T, Sameshima T, Miyao J, Furuta T, Baba S "Identification and quantitative determination of fentanyl metabolites in patients by gas chromatography--mass spectrometry." Anesthesiology 61 (1984): 73-7
- Haberer JP, Schoeffler P, Couderc E, Duvaldestin P "Fentanyl pharmacokinetics in anaesthetized patients with cirrhosis." Br J Anaesth 54 (1982): 1267-70
- McClain DA, Hug CC, Jr "Intravenous fentanyl kinetics." Clin Pharmacol Ther 28 (1980): 106-14
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. MS Contin (morphine)." Purdue Frederick Company PROD (2002):
- Dixon R, Crews T, Inturrisi C, Foley K "Levorphanol: pharmacokinetics and steady-state plasma concentrations in patients with pain." Res Commun Chem Pathol Pharmacol 41 (1983): 3-17
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- Otton SV, Schadel M, Cheung SW, Kaplan HL, Busto UE, Sellers EM "CYP2D6 phenotype determines the metabolic conversion of hydrocodone to hydromorphone." Clin Pharmacol Ther 54 (1993): 463-72
- Cone EJ, Darwin WD, Gorodetzky CW, Tan T "Comparative metabolism of hydrocodone in man, rat, guinea pig, rabbit, and dog." Drug Metab Dispos 6 (1978): 488-93
- Hasselstrom J, Sawe J "Morphine pharmacokinetics and metabolism in humans. Enterohepatic cycling and relative contribution of metabolites to active opioid concentrations." Clin Pharmacokinet 24 (1993): 344-54
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- Giacomini KM, Giacomini JC, Gibson TP, Levy G "Propoxyphene and norpropoxyphene plasma concentrations after oral propoxyphene in cirrhotic patients with and without surgically constructed portacaval shunt." Clin Pharmacol Ther 28 (1980): 417-24
- Flanagan RJ, Johnston A, White AS, Crome P "Pharmacokinetics of dextropropoxyphene and nordextropropoxyphene in young and elderly volunteers after single and multiple dextropropoxyphene dosage." Br J Clin Pharmacol 28 (1989): 463-9
- Chen ZR, Somogy AA, Reynolds G, Bochner F "Disposition and metabolism of codeine after single and chronic doses in one poor and seven extensive metabolisers." Br J Clin Pharmacol 31 (1991): 381-90
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- Hagen N, Thirlwell MP, Dhaliwal HS, Babul N, Harsanyi Z, Darke AC "Steady-state pharmacokinetics of hydromorphone and hydromorphone-3-glucuronide in cancer patients after immediate and controlled-release hydromorphone." J Clin Pharmacol 35 (1995): 37-44
- "Product Information. Alfenta (alfentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Sufenta (sufentanil)." Janssen Pharmaceuticals PROD (2001):
- Beckett AH, Vaughan DP, Essien EE "N-Oxidation--an important route in the metabolism of methadone in man." J Pharm Pharmacol 24 (1972): 244
- Beckett AH, Taylor JF, Casy AF, Hassan MM "The biotransformation of methadone in man: synthesis and identification of a major metabolite." J Pharm Pharmacol 20 (1968): 754-62
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- Dershwitz M, Randel GI, Rosow CE, Fragen RJ, Connors PM, Librojo ES, Shaw DL, Peng AW, Jamerson BD "Initial clinical experience with remifentanil, a new opioid metabolized by esterases." Anesth Analg 81 (1995): 619-23
- Dershwitz M, Hoke JF, Rosow CE, Michalowski P, Connors PM, Muir KT, Dienstag JL "Pharmacokinetics and pharmacodynamics of remifentanil in volunteer subjects with severe liver disease." Anesthesiology 84 (1996): 812-20
- Westmoreland CL, Hoke JF, Sebel PS, Hug CC Jr, Muir KT "Pharmacokinetics of remifentanil (GI87084B) and its major metabolite (GI90291) in patients undergoing elective inpatient surgery." Anesthesiology 79 (1993): 893-903
- "Product Information. Ultiva (remifentanil)." Mylan Institutional (formally Bioniche Pharma USA Inc) PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Nubain (nalbuphine)." Endo Laboratories LLC PROD (2001):
- "Product Information. Buprenex (buprenorphine)." Reckitt and Colman Pharmaceuticals Inc PROD (2001):
- "Product Information. Talwin NX (pentazocine)." Sanofi Winthrop Pharmaceuticals PROD (2001):
- "Product Information. Stadol (butorphanol)." Allscrips Pharmaceutical Company PROD (2001):
- "Product Information. Dalgan (dezocine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
- "Product Information. Orlaam (levomethadyl acetate)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Nucynta (tapentadol)." PriCara Pharmaceuticals (2009):
Narcotic analgesics (applies to Mepergan) prematurity
Major Potential Hazard, High plausibility. Applicable conditions: Prematurity/Underweight in Infancy
The use of narcotic (opioid) analgesic agents is contraindicated in premature infants. These agents may cross the immature blood-brain barrier to a greater extent than in adults, resulting in disproportionate respiratory depression.
References
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Multum Information Services, Inc. Expert Review Panel"
Opiate agonists (applies to Mepergan) acute alcohol intoxication
Major Potential Hazard, High plausibility.
The use of opiate agonists is contraindicated in patients with acute alcohol intoxication exhibiting depressed vital signs. The central nervous system depressant effects of opiate agonists may be additive with those of alcohol. Severe respiratory depression and death may occur. Therapy with opiate agonists should be administered cautiously in patients who might be prone to acute alcohol intake.
References
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. MS Contin (morphine)." Purdue Frederick Company PROD (2002):
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- "Multum Information Services, Inc. Expert Review Panel"
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- "Product Information. Sublimaze (fentanyl)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
- "Product Information. Nucynta (tapentadol)." PriCara Pharmaceuticals (2009):
Opiate agonists (applies to Mepergan) drug dependence
Major Potential Hazard, High plausibility. Applicable conditions: Drug Abuse/Dependence, Alcoholism
Opiate agonists have the potential to cause dependence and abuse. Tolerance as well as physical and psychological dependence can develop after prolonged use. Abrupt cessation, reduction in dosage, or administration of an opiate antagonist such as naloxone may precipitate withdrawal symptoms. In patients who have developed tolerance to an opiate agonist, overdosage can still produce respiratory depression and death, and cross-tolerance usually will occur with other agents in the class. Addiction-prone individuals, such as those with a history of alcohol or substance abuse, should be under careful surveillance or medical supervision when treated with opiate agonists. It may be prudent to refrain from dispensing large quantities of medication to these patients. After prolonged use or if dependency is suspected, withdrawal of opiate therapy should be undertaken gradually using a dosage-tapering schedule.
References
- Fishbain DA, Goldberg M, Rosomoff RS, Rosomoff H "Atypical withdrawal syndrome (organic delusional syndrome) secondary to oxycodone detoxification ." J Clin Psychopharmacol 8 (1988): 441-2
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. MS Contin (morphine)." Purdue Frederick Company PROD (2002):
- Miser AW, Chayt KJ, Sandlund JT, Cohen PS, Dothage JA, Miser JS "Narcotic withdrawal syndrome in young adults after the therapeutic use of opiates." Am J Dis Child 140 (1986): 603-4
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- Morrison AB "Toxicity and abuse of hydrocodone bitartrate." Can Med Assoc J 120 (1979): 1338
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- Azorlosa JL, Stitzer ML, Greenwald MK "Opioid physical dependence development - effects of single versus repeated morphine pretreatments and of subjects opioid exposure history." Psychopharmacology (Berl) 114 (1994): 71-80
- Strode SW "Propoxyphene dependence and withdrawal." Am Fam Physician 32 (1985): 105-8
- Wall R, Linford SM, Akhter MI "Addiction to Distalgesic (dextropropoxyphene)." Br Med J 280 (1980): 1213-4
- Salguero CH, Villarreal JE, Hug CC Jr, Domino EF "Propoxyphene dependence." JAMA 210 (1969): 135-6
- Claghorn JL, Schoolar JC "Propoxyphene hydrochloride, a drug of abuse." JAMA 196 (1966): 1089-91
- Whittington RM "Dextropropoxyphene addiction." Lancet 2 (1979): 743-4
- Collins GB, Kiefer KS "Propoxyphene dependence: an update." Postgrad Med 70 (1981): 57-61
- Ng B, Alvear M "Dextropropoxyphene addiction--a drug of primary abuse." Am J Drug Alcohol Abuse 19 (1993): 153-8
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- "Product Information. Sublimaze (fentanyl)." Janssen Pharmaceuticals PROD (2001):
- Hedenmalm K "A case of severe withdrawal syndrome due to dextropropoxyphene." Ann Intern Med 123 (1995): 473
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
- "Product Information. Nucynta (tapentadol)." PriCara Pharmaceuticals (2009):
Opiate agonists (applies to Mepergan) gastrointestinal obstruction
Major Potential Hazard, Moderate plausibility.
Opioid agonists are contraindicated in patients with known or suspected gastrointestinal obstruction, including paralytic ileus.
References
- "Product Information. Ultram (tramadol)." McNeil Pharmaceutical PROD (2001):
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Apadaz (acetaminophen-benzhydrocodone)." KemPharm, Inc (2018):
Opiate agonists (applies to Mepergan) hypotension
Major Potential Hazard, High plausibility. Applicable conditions: Dehydration, Shock
Opiate agonists can induce vasodilation and significant hypotension, particularly when given in high dosages and/or by rapid intravenous administration. Opiate analgesics cause vasodilatation that may exacerbate hypotension and hypoperfusion and, therefore, are contraindicated in circulatory shock. At therapeutic analgesic dosages, ambulatory patients are more likely to experience dizziness and hypotension than patients who are confined to bed. However, orthostatic hypotension may occur in supine patients upon rising. Therapy with opiate agonists should be administered cautiously and initiated at reduced dosages in patients with hypovolemia, or a predisposition to hypotension. When given by intramuscular or subcutaneous administration, clinicians should also be aware that impaired perfusion in these patients may prevent complete absorption of the drug. With repeated injections, an excessive amount may be absorbed suddenly if normal circulation is reestablished.
References
- Parke TJ, Nandi PR, Bird KJ, Jewkes DA "Profound hypotension following intravenous codeine phosphate: three case reports and some recommendations." Anaesthesia 47 (1992): 852-4
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. MS Contin (morphine)." Purdue Frederick Company PROD (2002):
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- Sebel PS, Bovill JG, Boekhorst RA, Rog N "Cardiovascular effects of high-dose fentanyl anaesthesia." Acta Anaesthesiol Scand 26 (1982): 308-15
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- "Product Information. Sublimaze (fentanyl)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Fentanyl Oralet (fentanyl)." Abbott Pharmaceutical, Abbott Park, IL.
- American Medical Association, Division of Drugs and Toxicology "Drug evaluations annual 1994." Chicago, IL: American Medical Association; (1994):
- Cox RG "Hypoxaemia and hypotension after intravenous codeine phosphate." Can J Anaesth 41 (1994): 1211-3
- "Product Information. Alfenta (alfentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Sufenta (sufentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- "Product Information. Ultiva (remifentanil)." Mylan Institutional (formally Bioniche Pharma USA Inc) PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
- "Product Information. Orlaam (levomethadyl acetate)." Roxane Laboratories Inc PROD (2001):
- "Product Information. DepoDur (morphine liposomal)." Endo Laboratories LLC (2004):
- "Product Information. Nucynta (tapentadol)." PriCara Pharmaceuticals (2009):
- "Product Information. Apadaz (acetaminophen-benzhydrocodone)." KemPharm, Inc (2018):
Opiate agonists (applies to Mepergan) intracranial pressure
Major Potential Hazard, High plausibility. Applicable conditions: Brain/Intracranial Tumor, Head Injury, Cerebral Vascular Disorder
The hypoventilation associated with administration of opiate agonists, particularly by the intravenous route, can induce cerebral hypoxia and vasodilatation with resultant increase in intracranial pressure. Opiate agonists should not be used in patients with suspected or known head injury or increased intracranial pressure. Also, clinicians treating such patients should be aware that opiate agonists may interfere with the evaluation of CNS function, especially with respect to consciousness levels, respiratory status, and pupillary changes.
References
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. MS Contin (morphine)." Purdue Frederick Company PROD (2002):
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- "Product Information. Sublimaze (fentanyl)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Fentanyl Oralet (fentanyl)." Abbott Pharmaceutical, Abbott Park, IL.
- American Medical Association, Division of Drugs and Toxicology "Drug evaluations annual 1994." Chicago, IL: American Medical Association; (1994):
- "Product Information. Alfenta (alfentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Sufenta (sufentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- "Product Information. Ultiva (remifentanil)." Mylan Institutional (formally Bioniche Pharma USA Inc) PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
- "Product Information. Orlaam (levomethadyl acetate)." Roxane Laboratories Inc PROD (2001):
- "Product Information. DepoDur (morphine liposomal)." Endo Laboratories LLC (2004):
- "Product Information. Nucynta (tapentadol)." PriCara Pharmaceuticals (2009):
- "Product Information. Apadaz (acetaminophen-benzhydrocodone)." KemPharm, Inc (2018):
Opiate agonists (applies to Mepergan) respiratory depression
Major Potential Hazard, High plausibility. Applicable conditions: Pulmonary Impairment, Brain/Intracranial Tumor, Head Injury, Altered Consciousness, Asphyxia, Cerebral Vascular Disorder, Respiratory Arrest
Opiate agonists may produce significant central nervous system and respiratory depression of varying duration, particularly when given in high dosages and/or by rapid intravenous administration. Apnea may result from decreased respiratory drive as well as increased airway resistance, and rigidity of respiratory muscles may occur during rapid IV administration or when these agents are used in the induction of anesthesia. At therapeutic analgesic dosages, the respiratory effects are usually not clinically important except in patients with preexisting pulmonary impairment. Therapy with opiate agonists should be avoided or administered with extreme caution and initiated at reduced dosages in patients with severe CNS depression; sleep apnea; hypoxia, anoxia, or hypercapnia; upper airway obstruction; chronic pulmonary insufficiency; a limited ventilatory reserve; or other respiratory disorders. In the presence of excessive respiratory secretions, the use of opiate agonists may also be problematic because they decrease ciliary activity and reduce the cough reflex. Caution is also advised in patients who may be at increased risk for respiratory depression, such as comatose patients or those with head injury, intracranial lesions, or intracranial hypertension. Clinical monitoring of pulmonary function is recommended, and equipment for resuscitation should be immediately available if parenteral or neuraxial routes are used. Naloxone may be administered to reverse clinically significant respiratory depression, which may be prolonged depending on the opioid agent, cumulative dose, and route of administration.
References
- Redpath JB, Pleuvry BJ "Double-blind comparison of the respiratory and sedative effects of codeine phosphate and (+/-)-glaucine phosphate in human volunteers." Br J Clin Pharmacol 14 (1982): 555-8
- Rigg JR, Ilsley AH, Vedig AE "Relationship of ventilatory depression to steady-state blood pethidine concentrations." Br J Anaesth 53 (1981): 613-9
- Samuels SI, Rabinov W "Difficulty reversing drug-induced coma in a patient with sleep apnea." Anesth Analg 65 (1986): 1222-4
- Elloway R, Sherman S, Maas L, et al. "Meperidine-induced bronchospasm." Gastrointest Endosc 38 (1992): 93
- Kreek MJ, Hartman N "Chronic use of opioids and antipsychotic drugs: side effects, effects on endogenous opioids, and toxicity." Ann N Y Acad Sci 398 (1982): 151-72
- Bellville JW, Forrest WH, Elashoff J, Laska E "Evaluating side effects of analgesics in a cooperative clinical study." Clin Pharmacol Ther 9 (1968): 303-13
- Bigler D, Eriksen J, Christensen CB "Prolonged respiratory depression caused by slow release morphine." Lancet 06/30/84 (1984): 1477
- Covington EC, Gonsalves-Ebrahim L, Currie KO, et al. "Severe respiratory depression from patient-controlled analgesia in renal failure." Psychosomatics 30 (1989): 226-8
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. MS Contin (morphine)." Purdue Frederick Company PROD (2002):
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- Sackner MA "Effects of hydrocodone bitartrate on breathing pattern of patients with chronic obstructive pulmonary disease and restrictive lung disease." Mt Sinai J Med 51 (1984): 222-6
- Comstock MK, Carter JG, Moyers JR, Stevens WC "Rigidity and hypercarbia associated with high dose fentanyl induction of anesthesia." Anesth Analg 60 (1981): 362-3
- Eisenach JC "Respiratory depression following intrathecal opioids." Anesthesiology 75 (1991): 712
- Palmer CM "Early respiratory depression following intrathecal fentanyl-morphine combination." Anesthesiology 74 (1991): 1153-5
- Brockway MS, Noble DW, Sharwood-Smith GH, McClure JH "Profound respiratory depression after extradural fentanyl." Br J Anaesth 64 (1990): 243-5
- Harper MH, Hickey RF, Cromwell TH, Linwood S "The magnitude and duration of respiratory depression produced by fentanyl and fentanyl plus droperidol in man." J Pharmacol Exp Ther 199 (1976): 464-8
- Varrassi G, Celleno D, Capogna G, et al. "Ventilatory effects of subarachnoid fentanyl in the elderly." Anaesthesia 47 (1992): 558-62
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- Ogawa K, Iranami H, Yoshiyama T, Maeda H, Hatano Y "Severe respiratory depression after epidural morphine in a patient with myotonic dystrophy." Can J Anaesth 40 (1993): 968-70
- Noble DW, Morrison LM, Brockway MS, Mcclure JH "Respiratory depression after extradural fentanyl." Br J Anaesth 72 (1994): 251
- Houghton IT, Aun CST, Wong YC, Chan K, Lau JTF, Oh TE "The respiratory depressant effect of morphine - a comparative study in three ethnic groups." Anaesthesia 49 (1994): 197-201
- Jackson FW "Fentanyl and the wooden chest." Gastroenterology 106 (1994): 820-1
- Etches RC "Respiratory depression associated with patient-controlled analgesia - a review of eight cases." Can J Anaesth 41 (1994): 125-32
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- "Product Information. Sublimaze (fentanyl)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Fentanyl Oralet (fentanyl)." Abbott Pharmaceutical, Abbott Park, IL.
- American Medical Association, Division of Drugs and Toxicology "Drug evaluations annual 1994." Chicago, IL: American Medical Association; (1994):
- Sandler AN, Baxter AD, Katz J, Samson B, Friedlander M, Norman P, Koren G, Roger S, Hull K, Klein J "A double-blind, placebo-controlled trial of transdermal fentanyl after abdominal hysterectomy: analgesic, respiratory, and pharmacokinetic effects." Anesthesiology 81 (1994): 1169-80
- "Product Information. Alfenta (alfentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Sufenta (sufentanil)." Janssen Pharmaceuticals PROD (2001):
- Hudson RJ "Apnoea and unconsciousness after apparent recovery from alfentanil- supplemented anaesthesia." Can J Anaesth 37 (1990): 255-7
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- Morley AD "Profound respiratory depression with morphine patient-controlled analgesia in an elderly patient." Anaesth Intensive Care 24 (1996): 287
- Amin HM, Sopchak AM, Esposito BF, Henson LG, Batenhorst RL, Fox AW, Camporesi EM "Naloxone-induced and spontaneous reversal of depressed ventilatory responses to hypoxia during and after continuous infusion of remifentanil or alfentanil." J Pharmacol Exp Ther 274 (1995): 34-9
- "Product Information. Ultiva (remifentanil)." Mylan Institutional (formally Bioniche Pharma USA Inc) PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
- "Product Information. Orlaam (levomethadyl acetate)." Roxane Laboratories Inc PROD (2001):
- "Product Information. DepoDur (morphine liposomal)." Endo Laboratories LLC (2004):
- "Product Information. Nucynta (tapentadol)." PriCara Pharmaceuticals (2009):
- "Product Information. Apadaz (acetaminophen-benzhydrocodone)." KemPharm, Inc (2018):
Phenothiazines (applies to Mepergan) acute alcohol intoxication
Major Potential Hazard, High plausibility. Applicable conditions: Alcoholism
The use of phenothiazines is contraindicated in patients with acute alcohol intoxication exhibiting depressed vital signs. The central nervous system depressant effects of phenothiazines may be additive with those of alcohol. Severe respiratory depression and respiratory arrest may occur. Therapy with phenothiazines should be administered cautiously in patients who might be prone to acute alcohol intake.
References
- "Product Information. Thorazine (chlorpromazine)." SmithKline Beecham PROD (2002):
- "Product Information. Sparine (promazine)." Wyeth-Ayerst Laboratories PROD (2001):
- "Product Information. Phenergan (promethazine)." Wyeth-Ayerst Laboratories PROD (2001):
- "Product Information. Prolixin (fluphenazine)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Compazine (prochlorperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Mellaril (thioridazine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Serentil (mesoridazine)." Boehringer-Ingelheim PROD (2001):
- "Product Information. Torecan (thiethylperazine)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Trilafon (perphenazine)." Schering Corporation PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
- "Product Information. Stelazine (trifluoperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Vesprin (triflupromazine)." Bristol-Myers Squibb PROD (2001):
Phenothiazines (applies to Mepergan) cardiovascular disease
Major Potential Hazard, Moderate plausibility. Applicable conditions: Dehydration, Cerebrovascular Insufficiency, History - Cerebrovascular Disease, History - Myocardial Infarction, Hypotension, Pheochromocytoma, Arrhythmias
Phenothiazines may cause hypotension (including orthostatic hypotension), reflex tachycardia, increased pulse rate, syncope, and dizziness, particularly after the first parenteral dose but rarely after the first oral dose. Low-potency agents such as chlorpromazine and thioridazine are more likely to induce these effects, which usually subside within the first couple of hours following administration. Tolerance to the hypotensive effects often develops after a few doses. Rarely, fatal cardiac arrest has occurred secondary to severe hypotension. Other reported adverse cardiovascular effects include edema, thrombosis, and ECG abnormalities such as PR and QT interval prolongation, diffuse T-wave flattening, and ST segment depression. Therapy with phenothiazines should be avoided or otherwise administered cautiously in patients with severe cardiovascular disease, pheochromocytoma, a predisposition to hypotension, or conditions that could be exacerbated by hypotension such as a history of myocardial infarction, angina, or ischemic stroke. Close monitoring of cardiovascular status, including ECG changes, is recommended at all dosages. If parenteral therapy is given, patients should be in a supine position during administration and for at least 30 to 60 minutes afterwards. Patients who experience orthostatic hypotension should be cautioned not to rise too abruptly. Occasionally, when severe, hypotension may require treatment with vasoconstrictive agents such as norepinephrine or phenylephrine. Epinephrine should not be used, however, since phenothiazines can reverse its vasopressor effects and cause a further lowering of blood pressure.
References
- Varia I, Krishnan R, Davidson J "Deep-vein thrombosis with antipsychotic drugs." Psychosomatics 24 (1983): 1097-8
- Schreiber G, Belmaker R "In vivo differentiation of cardiac vagal blocking effects of chlorpromazine and haloperidol." Biol Psychiatry 22 (1987): 1417-21
- Witz L, Shapiro M, Shenkman L "Chlorpromazine induced fluid retention masquerading as idiopathic oedema." Br Med J 294 (1987): 807-8
- Dorson P, Crismon M "Chlorpromazine accumulation and sudden death in a patient with renal insufficiency." Drug Intell Clin Pharm 22 (1988): 776-8
- Fruncillo R, Gibbons W, Vlasses P, Ferguson R "Severe hypotension associated with concurrent clonidine and antipsychotic medication." Am J Psychiatry 142 (1985): 274
- Stevenson R, Blanshard C, Patterson D "Ventricular fibrillation due to lithium withdrawal: an interaction with chlorpromazine?" Postgrad Med J 65 (1989): 936-8
- "Product Information. Thorazine (chlorpromazine)." SmithKline Beecham PROD (2002):
- "Product Information. Sparine (promazine)." Wyeth-Ayerst Laboratories PROD (2001):
- "Product Information. Phenergan (promethazine)." Wyeth-Ayerst Laboratories PROD (2001):
- Fletcher GF, Kazamias TM "Cardiotoxic effects of Mellaril: conduction disturbances and supraventricular arrhythmias." Am Heart J 78 (1969): 135-8
- Margolis J "Massive edema induced by thioridazine (Mellaril): an unusual complication." J Am Geriatr Soc 20 (1972): 593-4
- Kumar BB "Letter: Acute hypotension from thioridazine." JAMA 234 (1975): 1321
- Jones J, Sklar D, Dougherty J, White W "Randomized double-blind trial of intravenous prochlorperazine for the treatment of acute headache." JAMA 261 (1989): 1174-6
- "Product Information. Prolixin (fluphenazine)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Compazine (prochlorperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Mellaril (thioridazine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Serentil (mesoridazine)." Boehringer-Ingelheim PROD (2001):
- "Product Information. Torecan (thiethylperazine)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Trilafon (perphenazine)." Schering Corporation PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
- "Product Information. Stelazine (trifluoperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Vesprin (triflupromazine)." Bristol-Myers Squibb PROD (2001):
- Talbert RL, Yee GC, DiPiro JT, Matzke GR, Posey LM, Wells BG "Pharmacotherapy: A Pathophysiologic Approach" Stamford, CT: Appleton & Lange (1999):
Phenothiazines (applies to Mepergan) CNS depression
Major Potential Hazard, High plausibility. Applicable conditions: Altered Consciousness, Respiratory Arrest
The use of phenothiazines is contraindicated in comatose patients and patients with severe central nervous system depression. Phenothiazines may potentiate the CNS and respiratory depression in these patients.
References
- "Product Information. Thorazine (chlorpromazine)." SmithKline Beecham PROD (2002):
- "Product Information. Sparine (promazine)." Wyeth-Ayerst Laboratories PROD (2001):
- "Product Information. Phenergan (promethazine)." Wyeth-Ayerst Laboratories PROD (2001):
- "Product Information. Prolixin (fluphenazine)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Compazine (prochlorperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Mellaril (thioridazine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Serentil (mesoridazine)." Boehringer-Ingelheim PROD (2001):
- "Product Information. Torecan (thiethylperazine)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Trilafon (perphenazine)." Schering Corporation PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
- "Product Information. Stelazine (trifluoperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Vesprin (triflupromazine)." Bristol-Myers Squibb PROD (2001):
Phenothiazines (applies to Mepergan) head injury
Major Potential Hazard, High plausibility.
The use of phenothiazines is contraindicated in patients with suspected or established subcortical brain damage, with or without hypothalamic involvement. Phenothiazines can interfere with thermoregulatory mechanisms, and a hyperthermic reaction with temperatures in excess of 104 F may occur in such patients, sometimes not until 14 to 16 hours after drug administration.
References
- "Product Information. Thorazine (chlorpromazine)." SmithKline Beecham PROD (2002):
- "Product Information. Sparine (promazine)." Wyeth-Ayerst Laboratories PROD (2001):
- Dilsaver SC "Effects of neuroleptics on body temperature" J Clin Psychiatry 49 (1988): 78-9
- Caroff S, Rosenberg H, Gerber JC "Neuroleptic malignant syndrome and malignant hyperthermia" Lancet 1 (1983): 244
- Keshavan MS, Kambhampati RK "Prolonged fever without extrapyramidal symptoms during neuroleptic treatment" J Clin Psychopharmacol 9 (1989): 230-1
- "Product Information. Prolixin (fluphenazine)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Compazine (prochlorperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Mellaril (thioridazine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Serentil (mesoridazine)." Boehringer-Ingelheim PROD (2001):
- "Product Information. Torecan (thiethylperazine)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Trilafon (perphenazine)." Schering Corporation PROD (2001):
- "Product Information. Stelazine (trifluoperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Vesprin (triflupromazine)." Bristol-Myers Squibb PROD (2001):
Promethazine (applies to Mepergan) antidopaminergic effects 1
Major Potential Hazard, Moderate plausibility. Applicable conditions: Dehydration, Hypocalcemia, Tardive Dyskinesia, Neuroleptic Malignant Syndrome
Promethazine has weak central antidopaminergic activity. While its use is rarely associated with adverse effects secondary to dopaminergic blockade, large doses have produced extrapyramidal reactions. During chronic administration and/or high-dose therapy, the usual contraindications, warnings and precautions applicable to phenothiazines should be observed with promethazine.
References
- Nicholson AN "Central effects of H1 and H2 antihistamines." Aviat Space Environ Med 56 (1985): 293-8
- Schwinghammer TL, Kroboth FJ, Juhl RP "Extrapyramidal reaction secondary to oral promethazine." Clin Pharm 3 (1984): 83-5
- "Product Information. Phenergan (promethazine)." Wyeth-Ayerst Laboratories PROD (2001):
Promethazine (applies to Mepergan) asthma
Major Potential Hazard, High plausibility. Applicable conditions: Pulmonary Impairment
Promethazine is contraindicated for use in the treatment of lower respiratory tract symptoms including asthma. Furthermore, promethazine tablets may lead to potentially fatal respiratory depression, and its use should be avoided in patients with compromised respiratory function such as patients with COPD, and sleep apnea.
References
- "Product Information. Phenergan (promethazine)." Wyeth-Ayerst Laboratories PROD (2001):
Antihistamines (applies to Mepergan) anticholinergic effects
Moderate Potential Hazard, High plausibility. Applicable conditions: Gastrointestinal Obstruction, Glaucoma/Intraocular Hypertension, Urinary Retention
Antihistamines often have anticholinergic activity, to which elderly patients are particularly sensitive. Therapy with antihistamines should be administered cautiously, if at all, in patients with preexisting conditions that are likely to be exacerbated by anticholinergic activity, such as urinary retention or obstruction; angle-closure glaucoma, untreated intraocular hypertension, or uncontrolled primary open-angle glaucoma; and gastrointestinal obstructive disorders. Conventional, first-generation antihistamines such as the ethanolamines (bromodiphenhydramine, carbinoxamine, clemastine, dimenhydrinate, diphenhydramine, doxylamine, phenyltoloxamine) tend to exhibit substantial anticholinergic effects. In contrast, the newer, relatively nonsedating antihistamines (e.g., cetirizine, fexofenadine, loratadine) reportedly have low to minimal anticholinergic activity at normally recommended dosages and may be appropriate alternatives.
References
- Schuller DE, Turkewitz D "Adverse effects of antihistamines." Postgrad Med 79 (1986): 75-86
- "Product Information. Dimetane (brompheniramine)." Wyeth-Ayerst Laboratories PROD (2002):
- "Product Information. Chlor-Trimeton (chlorpheniramine)." Schering-Plough PROD
- "Product Information. Periactin (cyproheptadine)." Merck & Co., Inc PROD (2002):
- "Product Information. Benadryl (diphenhydramine)." Parke-Davis PROD (2002):
- "Product Information. Phenergan (promethazine)." Wyeth-Ayerst Laboratories PROD (2001):
- "Product Information. Tavist (clemastine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Antivert (meclizine)." Roerig Division PROD (2001):
- "Product Information. Marezine (cyclizine)." Glaxo Wellcome PROD (2001):
- "Product Information. Optimine (azatadine)." Schering Corporation PROD (2001):
- "Product Information. Semprex-D (acrivastine-pseudoephedrine)." Endo Laboratories LLC PROD (2001):
- "Product Information. Zyrtec (cetirizine)." Pfizer U.S. Pharmaceuticals PROD (2001):
- "Product Information. Drixoral (dextromethorphan)." Schering-Plough PROD (2001):
- "Product Information. Poly-Histine-D (pyrilamine)." Bock Pharmacal Company PROD (2001):
- Watemberg NM, Roth KS, Alehan FK, Epstein CE "Central anticholinergic syndrome on therapeutic doses of cyproheptadine." Pediatrics 103 (1999): 158-60
- "Product Information. Vistaril (hydroxyzine)." Pfizer U.S. Pharmaceuticals PROD (2001):
- "Product Information. Dramamine (dimenhydrinate)." Pharmacia and Upjohn PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
- Talbert RL, Yee GC, DiPiro JT, Matzke GR, Posey LM, Wells BG "Pharmacotherapy: A Pathophysiologic Approach" Stamford, CT: Appleton & Lange (1999):
Antihistamines (applies to Mepergan) asthma/COPD
Moderate Potential Hazard, Moderate plausibility. Applicable conditions: Chronic Obstructive Pulmonary Disease
It has been suggested that the anticholinergic effect of antihistamines may reduce the volume and cause thickening of bronchial secretions, resulting in obstruction of respiratory tract. Some manufacturers and clinicians recommend that therapy with antihistamines be administered cautiously in patients with asthma or chronic obstructive pulmonary disease.
References
- "Product Information. Dimetane (brompheniramine)." Wyeth-Ayerst Laboratories PROD (2002):
- "Product Information. Chlor-Trimeton (chlorpheniramine)." Schering-Plough PROD
- "Product Information. Periactin (cyproheptadine)." Merck & Co., Inc PROD (2002):
- "Product Information. Benadryl (diphenhydramine)." Parke-Davis PROD (2002):
- "Product Information. Phenergan (promethazine)." Wyeth-Ayerst Laboratories PROD (2001):
- Maddox DE, Reed CE "Clinical pharmacodynamics of antihistamines." Ann Allergy 59 (1987): 43-8
- "Product Information. Tavist (clemastine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Antivert (meclizine)." Roerig Division PROD (2001):
- "Product Information. Marezine (cyclizine)." Glaxo Wellcome PROD (2001):
- "Product Information. Optimine (azatadine)." Schering Corporation PROD (2001):
- "Product Information. Semprex-D (acrivastine-pseudoephedrine)." Endo Laboratories LLC PROD (2001):
- "Product Information. Drixoral (dextromethorphan)." Schering-Plough PROD (2001):
- "Product Information. Poly-Histine-D (pyrilamine)." Bock Pharmacal Company PROD (2001):
- "Product Information. Vistaril (hydroxyzine)." Pfizer U.S. Pharmaceuticals PROD (2001):
- "Product Information. Dramamine (dimenhydrinate)." Pharmacia and Upjohn PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
Narcotic analgesics (applies to Mepergan) adrenal insufficiency
Moderate Potential Hazard, Moderate plausibility.
Patients with Addison's disease may have increased risk of respiratory depression and prolonged CNS depression associated with the use of narcotic (opioid) analgesic agents. Conversely, these agents may cause or potentiate adrenal insufficiency. Therapy with opioids should be administered cautiously and initiated at reduced dosages in patients with adrenocortical insufficiency. Subsequent doses should be titrated based on individual response rather than a fixed dosing schedule.
References
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. Roxanol (morphine)." Roxane Laboratories Inc PROD (2002):
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- "Product Information. Sublimaze (fentanyl)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Fentanyl Oralet (fentanyl)." Abbott Pharmaceutical, Abbott Park, IL.
- "Product Information. Alfenta (alfentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Sufenta (sufentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- "Product Information. Ultiva (remifentanil)." Mylan Institutional (formally Bioniche Pharma USA Inc) PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Stadol (butorphanol nasal)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Nubain (nalbuphine)." Endo Laboratories LLC PROD (2001):
- "Product Information. Buprenex (buprenorphine)." Reckitt and Colman Pharmaceuticals Inc PROD (2001):
- "Product Information. Talwin NX (pentazocine)." Sanofi Winthrop Pharmaceuticals PROD (2001):
- "Product Information. Stadol (butorphanol)." Allscrips Pharmaceutical Company PROD (2001):
- "Product Information. Dalgan (dezocine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- Braunwald E, Hauser SL, Kasper DL, Fauci AS, Isselbacher KJ, Longo DL, Martin JB, eds., Wilson JD "Harrison's Principles of Internal Medicine." New York, NY: McGraw-Hill Health Professionals Division (1998):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
- "Product Information. Orlaam (levomethadyl acetate)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Olinvyk (oliceridine)." Trevena Inc (2020):
Narcotic analgesics (applies to Mepergan) biliary spasm
Moderate Potential Hazard, Moderate plausibility. Applicable conditions: Biliary Obstruction, Gallbladder Disease
Narcotic (opioid) analgesic agents increase smooth muscle tone in the biliary tract, which can lead to spasm in the sphincter of Oddi causing biliary colic. Increase in serum amylase levels has also been reported. Therapy with opioids should be administered cautiously in patients with biliary tracts disease, gallbladder disease and acute pancreatitis.
References
- Jones RM, Fiddian-Green R, Knight PR "Narcotic-induced choledochoduodenal sphincter spasm reversed by glucagon." Anesth Analg 59 (1980): 946-7
- Hey VM, Ostick DG, Mazumder JK, Lord WD "Pethidine, metoclopramide and the gastro-oesophageal sphincter." Anaesthesia 36 (1981): 173-6
- Lang DW, Pilon RN "Naloxone reversal of morphine-induced biliary colic." Anesth Analg 59 (1980): 619-20
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. MS Contin (morphine)." Purdue Frederick Company PROD (2002):
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- McCammon RL, Viegas OJ, Stoelting RK, Dryden GE "Naloxone reversal of choledochoduodenal sphincter spasm associated with narcotic administration." Anesthesiology 48 (1978): 437
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- Zsigmond EK, Vieira ZEG, Duarte B, Renigers SA, Hirota K "Double-blind placebo-controlled ultrasonographic confirmation of constriction of the common bile duct by morphine." Int J Clin Pharmacol Ther Toxicol 31 (1993): 506-9
- Ford MJ, Kellett RJ, Busuttil A, Finlayson ND "Dextropropoxyphene and jaundice." Br Med J 2 (1977): 674
- Daikos GK, Kosmidis JC "Propoxyphene jaundice." JAMA 232 (1975): 835
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- "Product Information. Sublimaze (fentanyl)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Fentanyl Oralet (fentanyl)." Abbott Pharmaceutical, Abbott Park, IL.
- American Medical Association, Division of Drugs and Toxicology "Drug evaluations annual 1994." Chicago, IL: American Medical Association; (1994):
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Stadol (butorphanol nasal)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Nubain (nalbuphine)." Endo Laboratories LLC PROD (2001):
- "Product Information. Buprenex (buprenorphine)." Reckitt and Colman Pharmaceuticals Inc PROD (2001):
- "Product Information. Talwin NX (pentazocine)." Sanofi Winthrop Pharmaceuticals PROD (2001):
- "Product Information. Stadol (butorphanol)." Allscrips Pharmaceutical Company PROD (2001):
- "Product Information. Dalgan (dezocine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
- "Product Information. Orlaam (levomethadyl acetate)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Nucynta (tapentadol)." PriCara Pharmaceuticals (2009):
Narcotic analgesics (applies to Mepergan) renal dysfunction
Moderate Potential Hazard, High plausibility.
Although narcotic (opioid) analgesic agents are generally metabolized by the liver, renal impairment can alter the elimination of these agents and their metabolites (some of which are pharmacologically active), resulting in drug accumulation and increased risk of toxicity. Therapy with opioids should be administered cautiously and initiated at reduced dosages in patients with significantly impaired renal function. Subsequent doses should be titrated based on individual response rather than a fixed dosing schedule.
References
- Findlay JW, Butz RF, Welch RM "Codeine kinetics as determined by radioimmunoassay." Clin Pharmacol Ther 22 (1977): 439-46
- Barnes JN, Williams AJ, Tomson MJ, et al. "Dihydrocodeine in renal failure: further evidence for an important role of the kidney in the handling of opioid drugs." Br Med J (Clin Res Ed) 290 (1985): 740-2
- Matske GR, Chan GL, Abraham PA "Codeine dosage in renal failure." Clin Pharm 5 (1986): 15-6
- Guy DR, Awni WM, Findlay JW, et al. "Pharmacokinetics and pharmacodynamics of codeine in end-stage renal disease." Clin Pharmacol Ther 43 (1988): 63-71
- Charuvastra VC, Ouren J "Renal failure and treatment of a methadone maintenance patient." Med J Aust 09/24/77 (1977): 433-4
- Verbeeck RK, Branch RA, Wilkinson GR "Drug metabolites in renal failure: pharmacokinetic and clinical implications." Clin Pharmacokinet 6 (1981): 329-45
- Drayer DE "Active drug metabolites and renal failure." Am J Med 62 (1977): 486-9
- Drayer DE "Pharmacologically active drug metabolites: therapeutic and toxic activities, plasma and urine data in man, accumulation in renal failure." Clin Pharmacokinet 1 (1976): 426-43
- Parab PV, Ritschel WA, Coyle DE, et al. "Pharmacokinetics of hydromorphone after intravenous, peroral and rectal administration to human subjects." Biopharm Drug Dispos 9 (1988): 187-99
- Hill HF, Coda BA, Tanaka A, Schaffer R "Multiple-dose evaluation of intravenous hydromorphone pharmacokinetics in normal human subjects." Anesth Analg 72 (1991): 330-6
- Poyhia R, Seppala T, Olkkola KT, Kalso E "The pharmacokinetics and metabolism of oxycodone after intramuscular and oral administration to healthy subjects." Br J Clin Pharmacol 33 (1992): 617-21
- Wolff J, Bigler D, Christensen CB, et al. "Influence of renal function on the elimination of morphine and morphine glucoronides." Eur J Clin Pharmacol 34 (1988): 353-7
- Covington EC, Gonsalves-Ebrahim L, Currie KO, et al. "Severe respiratory depression from patient-controlled analgesia in renal failure." Psychosomatics 30 (1989): 226-8
- Poyhia R, Olkkola KT, Seppala T, Kalso E "The pharmacokinetics of oxycodone after intravenous injection in adults." Br J Clin Pharmacol 32 (1991): 516-8
- Glare PA, Walsh TD "Clinical pharmacokinetics of morphine." Ther Drug Monit 13 (1991): 1-23
- Gram LF, Schou J, Way WL, et al. "delta-Propoxyphene kinetics after single oral and intravenous doses in man." Clin Pharmacol Ther 26 (1979): 473-82
- Bechtel WD, Sinterhauf K "Plasma level and renal excretion of [3H] codeine phosphate in man and in the dog." Arzneimittelforschung 28 (1978): 308-11
- Wolfert AI, Sica DA "Narcotic usage in renal failure." Int J Artif Organs 11 (1988): 411-5
- Inturrisi CE "Disposition of narcotics in patients with renal disease." Am J Med 62 (1977): 528-9
- Chan K, Jennings F, Orme ML "Pharmacokinetics of low-dose intravenous pethidine in patients with renal dysfunction." J Clin Pharmacol 27 (1987): 516-22
- Chauvin M, Sandouk P, Scherrmann JM, Farinotti R, Strumza P, Duvaldestin P "Morphine pharmacokinetics in renal failure." Anesthesiology 66 (1987): 327-31
- Aitkenhead AR, Vater M, Achola K, Cooper CM, Smith G "Pharmacokinetics of single-dose i.v. morphine in normal volunteers and patients with end-stage renal failure." Br J Anaesth 56 (1984): 813-9
- Sawe J, Odar-Cederlof I "Kinetics of morphine in patients with renal failure." Eur J Clin Pharmacol 32 (1987): 377-82
- Baselt RC, Casarett LJ "Urinary excretion of methadone in man." Clin Pharmacol Ther 13 (1972): 64-70
- Kreek MJ, Schecter AJ, Gutjahr CL, et al. "Methadone use in patients with chronic renal failure." Drug Alcohol Depend 5 (1980): 197-205
- Leow KP, Smith MT, Williams B, Cramond T "Single-dose and steady-state pharmacokinetics and pharmacodynamics of oxycodone in patients with cancer." Clin Pharmacol Ther 52 (1992): 487-95
- Leow KP, Smith MT, Watt JA, Williams BE, Cramond T "Comparative oxycodone pharmacokinetics in humans after intravenous, oral, and rectal administration." Ther Drug Monit 14 (1992): 479-84
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. MS Contin (morphine)." Purdue Frederick Company PROD (2002):
- Dixon R, Crews T, Inturrisi C, Foley K "Levorphanol: pharmacokinetics and steady-state plasma concentrations in patients with pain." Res Commun Chem Pathol Pharmacol 41 (1983): 3-17
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- Hanna MH, D'Costa F, Peat SJ, Fung C, Venkat N, Zilkha TR, Davies S "Morphine-6-glucuronide disposition in renal impairment." Br J Anaesth 70 (1993): 511-4
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- Gibson TP, Giacomini KM, Briggs WA, Whitman W, Levy G "Propoxyphene and norpropoxyphene plasma concentrations in the anephric patient." Clin Pharmacol Ther 27 (1980): 665-70
- Flanagan RJ, Johnston A, White AS, Crome P "Pharmacokinetics of dextropropoxyphene and nordextropropoxyphene in young and elderly volunteers after single and multiple dextropropoxyphene dosage." Br J Clin Pharmacol 28 (1989): 463-9
- Giacomini KM, Gibson TP, Levy G "Plasma protein binding of d-propoxyphene in normal subjects and anephric patients." J Clin Pharmacol 18 (1978): 106-9
- Sjogren P, Dragsted L, Christensen CB "Myoclonic spasms during treatment with high doses of intravenous morphine in renal failure." Acta Anaesthesiol Scand 37 (1993): 780-2
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- Dhonneur G, Gilton A, Sandouk P, Scherrmann JM, Duvaldestin P "Plasma and cerebrospinal fluid concentrations of morphine and morphine glucuronides after oral morphine - the influence of renal failure." Anesthesiology 81 (1994): 87-93
- "Product Information. Alfenta (alfentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Sufenta (sufentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- "Product Information. Ultiva (remifentanil)." Mylan Institutional (formally Bioniche Pharma USA Inc) PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Nubain (nalbuphine)." Endo Laboratories LLC PROD (2001):
- "Product Information. Buprenex (buprenorphine)." Reckitt and Colman Pharmaceuticals Inc PROD (2001):
- "Product Information. Talwin NX (pentazocine)." Sanofi Winthrop Pharmaceuticals PROD (2001):
- "Product Information. Stadol (butorphanol)." Allscrips Pharmaceutical Company PROD (2001):
- "Product Information. Dalgan (dezocine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
- "Product Information. Orlaam (levomethadyl acetate)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Nucynta (tapentadol)." PriCara Pharmaceuticals (2009):
Narcotic analgesics (applies to Mepergan) seizure disorders
Moderate Potential Hazard, Moderate plausibility. Applicable conditions: Seizures
Narcotic (opioid) analgesic agents may exacerbate seizures in patients with seizure disorders and, at higher dosages, have been reported to induce seizures in patients without previous history of seizures. The proconvulsant activity may be the greatest with meperidine, the active metabolite of which is thought to be responsible. Therapy with opioids should be administered cautiously in patients with or predisposed to seizures.
References
- Kaiko RF, Foley KM, Grabinski PY, et al. "Central nervous system excitatory effects of meperidine in cancer patients." Ann Neurol 13 (1983): 180-5
- Goetting MG, Thirman MJ "Neurotoxicity of meperidine." Ann Emerg Med 14 (1985): 1007-9
- Mauro VF, Bonfiglio MF, Spunt AL "Meperidine-induced seizure in a patient without renal dysfunction or sickle cell anemia." Clin Pharm 5 (1986): 837-9
- Reutens DC, Stewart-Wynne EG "Norpethidine induced myoclonus in a patient with renal failure." J Neurol Neurosurg Psychiatry 52 (1989): 1450-1
- Armstrong PJ, Bersten A "Normeperidine toxicity." Anesth Analg 65 (1986): 536-8
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. Roxanol (morphine)." Roxane Laboratories Inc PROD (2002):
- "Product Information. MS Contin (morphine)." Purdue Frederick Company PROD (2002):
- Babul N, Darke AC "Putative role of hydromorphone metabolites in myoclonus." Pain 51 (1992): 260-1
- Hagmeyer KO, Mauro LS, Mauro VF "Meperidine-related seizures associated with patient-controlled analgesia pumps." Ann Pharmacother 27 (1993): 29-32
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- Sebel PS, Bovill JG "Fentanyl and convulsions." Anesth Analg 62 (1983): 858-9
- Rao TL, Mummaneni N, El-Etr AA "Convulsions: an unusual response to intravenous fentanyl administration." Anesth Analg 61 (1982): 1020-1
- Goroszeniuk T, Albin M, Jones RM "Generalized grand mal seizure after recovery from uncomplicated fentanyl-etomidate anesthesia." Anesth Analg 65 (1986): 979-81
- Hoien AO "Another case of grand mal seizure after fentanyl administration." Anesthesiology 60 (1984): 387-8
- Safwat AM, Daniel D "Grand mal seizure after fentanyl administration." Anesthesiology 59 (1983): 78
- Smith NT, Benthuysen JL, Bickford RG, Sanford TJ, Blasco T, Duke PC, Head N, Dec-Silver H "Seizures during opioid anesthetic induction--are they opioid-induced rigidity?" Anesthesiology 71 (1989): 852-62
- Benthuysen JL, Stanley TH "Concerning the possible nature of reported fentanyl seizures." Anesthesiology 62 (1985): 205
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- Stone PA, Macintyre PE, Jarvis DA "Norpethidine toxicity and patient controlled analgesia." Br J Anaesth 71 (1993): 738-40
- Sjogren P, Dragsted L, Christensen CB "Myoclonic spasms during treatment with high doses of intravenous morphine in renal failure." Acta Anaesthesiol Scand 37 (1993): 780-2
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- "Product Information. Sublimaze (fentanyl)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Fentanyl Oralet (fentanyl)." Abbott Pharmaceutical, Abbott Park, IL.
- "Product Information. Alfenta (alfentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Sufenta (sufentanil)." Janssen Pharmaceuticals PROD (2001):
- Strong WE, Matson M "Probable seizure after alfentanil." Anesth Analg 68 (1989): 692-3
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- "Product Information. Ultiva (remifentanil)." Mylan Institutional (formally Bioniche Pharma USA Inc) PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Stadol (butorphanol nasal)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Nubain (nalbuphine)." Endo Laboratories LLC PROD (2001):
- "Product Information. Buprenex (buprenorphine)." Reckitt and Colman Pharmaceuticals Inc PROD (2001):
- "Product Information. Talwin NX (pentazocine)." Sanofi Winthrop Pharmaceuticals PROD (2001):
- "Product Information. Stadol (butorphanol)." Allscrips Pharmaceutical Company PROD (2001):
- "Product Information. Dalgan (dezocine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
- "Product Information. Orlaam (levomethadyl acetate)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Nucynta (tapentadol)." PriCara Pharmaceuticals (2009):
Narcotic analgesics (applies to Mepergan) urinary retention
Moderate Potential Hazard, Moderate plausibility.
Narcotic (opioid) analgesic agents may inhibit the urinary voiding reflex and increase the tone of the vesical sphincter in the bladder. Acute urinary retention requiring catheterization may occur, particularly in patients with prostatic hypertrophy or urethral stricture and in elderly patients. These agents may also decrease urine production via direct effects on the kidney and central stimulation of the release of vasopressin. Therapy with opioids should be administered cautiously in patients with or predisposed to urinary retention and/or oliguria. The effects on smooth muscle tone appear to be the most pronounced with morphine.
References
- Kreek MJ, Hartman N "Chronic use of opioids and antipsychotic drugs: side effects, effects on endogenous opioids, and toxicity." Ann N Y Acad Sci 398 (1982): 151-72
- Petersen TK, Husted SE, Rybro L, et al. "Urinary retention during I.M. and extradural morphine analgesia." Br J Anaesth 54 (1982): 1175-8
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. Roxanol (morphine)." Roxane Laboratories Inc PROD (2002):
- Petros JG, Mallen JK, Howe K, Rimm EB, Robillard RJ "Patient-controlled analgesia and postoperative urinary retention after open appendectomy." Surg Gynecol Obstet 177 (1993): 172-5
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- "Product Information. Sublimaze (fentanyl)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Fentanyl Oralet (fentanyl)." Abbott Pharmaceutical, Abbott Park, IL.
- American Medical Association, Division of Drugs and Toxicology "Drug evaluations annual 1994." Chicago, IL: American Medical Association; (1994):
- "Product Information. Alfenta (alfentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Sufenta (sufentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- "Product Information. Ultiva (remifentanil)." Mylan Institutional (formally Bioniche Pharma USA Inc) PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Stadol (butorphanol nasal)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Nubain (nalbuphine)." Endo Laboratories LLC PROD (2001):
- "Product Information. Buprenex (buprenorphine)." Reckitt and Colman Pharmaceuticals Inc PROD (2001):
- "Product Information. Talwin NX (pentazocine)." Sanofi Winthrop Pharmaceuticals PROD (2001):
- "Product Information. Stadol (butorphanol)." Allscrips Pharmaceutical Company PROD (2001):
- "Product Information. Dalgan (dezocine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
- "Product Information. Orlaam (levomethadyl acetate)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Nucynta (tapentadol)." PriCara Pharmaceuticals (2009):
Opiate agonists (applies to Mepergan) arrhythmias
Moderate Potential Hazard, Moderate plausibility.
Opiate agonists have cholinergic activity. Large doses and/or rapid intravenous administration may produce bradycardia and arrhythmias via stimulation of medullary vagal nuclei. Therapy with opiate agonists should be administered cautiously in patients with a history of arrhythmias. Clinical monitoring of cardiovascular status is recommended during therapy.
References
- "Product Information. Calcidrine (codeine)." Abbott Pharmaceutical PROD (2002):
- "Product Information. Demerol (meperidine)." Sanofi Winthrop Pharmaceuticals PROD (2002):
- "Product Information. Dolophine (methadone)." Lilly, Eli and Company PROD (2002):
- "Product Information. MS Contin (morphine)." Purdue Frederick Company PROD (2002):
- "Product Information. Levo-Dromoran (levorphanol)." Roche Laboratories PROD (2001):
- Hilgenberg JC, Johantgen WC "Bradycardia after intravenous fentanyl during subarachnoid anesthesia." Anesth Analg 59 (1980): 162-3
- Blair JR, Pruett JK, Crumrine RS, Balser JJ "Prolongation of QT interval in association with the administration of large doses of opiates." Anesthesiology 67 (1987): 442-3
- Sebel PS, Bovill JG, Boekhorst RA, Rog N "Cardiovascular effects of high-dose fentanyl anaesthesia." Acta Anaesthesiol Scand 26 (1982): 308-15
- "Product Information. Dilaudid (hydromorphone)." Knoll Pharmaceutical Company PROD (2001):
- Heaney RM "Left bundle branch block associated with propoxyphene hydrochloride poisoning." Ann Emerg Med 12 (1983): 780-2
- "Product Information. Darvon (propoxyphene)." Lilly, Eli and Company PROD (2001):
- "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
- "Product Information. Sublimaze (fentanyl)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Alfenta (alfentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. Sufenta (sufentanil)." Janssen Pharmaceuticals PROD (2001):
- "Product Information. OxyContin (oxycodone)." Purdue Frederick Company PROD (2001):
- "Product Information. Ultiva (remifentanil)." Mylan Institutional (formally Bioniche Pharma USA Inc) PROD (2001):
- "Product Information. Kadian (morphine)." Astra-Zeneca Pharmaceuticals PROD (2001):
- "Product Information. Vicoprofen (hydrocodone-ibuprofen)." Knoll Pharmaceutical Company PROD (2001):
- "Product Information. Opium (opium)." Lilly, Eli and Company (2022):
- "Product Information. Numorphan (oxymorphone)." Endo Laboratories LLC PROD (2001):
Phenothiazines (applies to Mepergan) breast cancer
Moderate Potential Hazard, Moderate plausibility.
The chronic use of phenothiazines is associated with persistent elevations in prolactin levels. Based on in vitro data, approximately one-third of human breast cancers are thought to be prolactin-dependent. The clinical significance of this observation is unknown. Chronic administration of neuroleptic drugs has been associated with mammary tumorigenesis in rodent studies but not in human clinical or epidemiologic studies. Therapy with phenothiazines should be administered cautiously in patients with existing or suspected malignancy of the breast.
References
- Ash PR, Bouma D "Exaggerated hyperprolactinemia in response to thiothixene ." Arch Neurol 38 (1981): 534-5
- Ristic PI, Ory SJ, Lurain JR "Endometrial adenocarcinoma associated with drug-induced hyperprolactinemia." Obstet Gynecol 67 (1986): s86-8
- "Product Information. Thorazine (chlorpromazine)." SmithKline Beecham PROD (2002):
- "Product Information. Sparine (promazine)." Wyeth-Ayerst Laboratories PROD (2001):
- Kane JM "Antipsychotic drug side effects: their relationship to dose." J Clin Psychiatry 46 (1985): 16-21
- Gift T, Plum K, Price M "Depot fluphenazine and plasma prolactin." Prog Neuropsychopharmacol Biol Psychiatry 9 (1985): 407-12
- "Product Information. Prolixin (fluphenazine)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Compazine (prochlorperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Mellaril (thioridazine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Serentil (mesoridazine)." Boehringer-Ingelheim PROD (2001):
- "Product Information. Torecan (thiethylperazine)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Trilafon (perphenazine)." Schering Corporation PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
- "Product Information. Stelazine (trifluoperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Vesprin (triflupromazine)." Bristol-Myers Squibb PROD (2001):
Phenothiazines (applies to Mepergan) dystonic reactions
Moderate Potential Hazard, Moderate plausibility. Applicable conditions: Dehydration, Hypocalcemia
Phenothiazines may cause acute, dose-related dystonic reactions secondary to central dopaminergic blockade. These reactions are characterized by spastic contraction of discrete muscle groups and may include torticollis, opisthotonos, carpopedal spasm, trismus, difficulty swallowing, perioral spasms with protrusion of the tongue, and oculogyric crisis. Onset is usually within 24 to 96 hours following initiation of therapy or an increase in dosage. Risk factors include young age, male gender, use of high-potency agents (e.g., fluphenazine, perphenazine, trifluoperazine), high dosages, and IM administration. Therapy with phenothiazines should be administered cautiously in patients, particularly children, with hypocalcemia or severe dehydration, since these patients may be more susceptible to dystonic reactions. Most symptoms subside within a few hours and are almost always reversible within 24 to 48 hours following withdrawal of therapy. However, severe reactions such as laryngospasm may be life-threatening and require appropriate supportive therapy. Parenteral administration of an anticholinergic antiparkinsonian agent (e.g., benztropine, trihexyphenidyl) or diphenhydramine usually produces a prompt response and may be given orally for short-term maintenance to prevent recurrence of symptoms if phenothiazine therapy must be continued.
References
- Wood G, Waters A "Prolonged dystonic reaction to chlorpromazine in myxoedema coma." Postgrad Med J 56 (1980): 192-3
- Nahata MC, Clotz MA, Krogg EA "Adverse effects of meperidine, promethazine, and chlorpromazine for sedation in pediatric patients." Clin Pediatr (Phila) 24 (1985): 558-60
- Schwinghammer TL, Kroboth FJ, Juhl RP "Extrapyramidal reaction secondary to oral promethazine." Clin Pharm 3 (1984): 83-5
- Marcotte DB "Neuroleptics and neurologic reactions." South Med J 66 (1973): 321-4
- "Product Information. Thorazine (chlorpromazine)." SmithKline Beecham PROD (2002):
- "Product Information. Sparine (promazine)." Wyeth-Ayerst Laboratories PROD (2001):
- "Product Information. Phenergan (promethazine)." Wyeth-Ayerst Laboratories PROD (2001):
- Idzorek S "Antiparkinsonian agents and fluphenazine decanoate." Am J Psychiatry 133 (1976): 80-2
- Bailie GR, Nelson MV, Krenzelok EP, Lesar T "Unusual treatment response of a severe dystonia to diphenhydramine." Ann Emerg Med 16 (1987): 705-8
- West D "Dangers of fluphenazine." Br J Psychiatry 117 (1970): 718-9
- Curson DA, Barnes TR, Bamber RW, Platt SD, Hirsch SR, Duffy JC "Long-term depot maintenance of chronic schizophrenic out-patients: the seven year follow-up of the Medical Research Council fluphenazine/placebo trial. II. The incidence of compliance problems,side-effects, neurotic symptoms and depression" Br J Psychiatry 146 (1985): 469-74
- Singh H, Levinson DF, Simpson GM, Lo ES, Friedman E "Acute dystonia during fixed-dose neuroleptic treatment." J Clin Psychopharmacol 10 (1990): 389-96
- Oyewumi LK, Lapierre YD, Gray R, Batth S, Gelfand R "Abnormal involuntary movements in patients on long-acting neuroleptics." Prog Neuropsychopharmacol Biol Psychiatry 7 (1983): 719-23
- Reecer MV, Clinchot DM, Tipton DB "Drug-induced dystonia in a patient with C4 quadriplegia. Case report." Am J Phys Med Rehabil 72 (1993): 97-8
- Sheppard C, Merlis S "Drug-induced extrapyramidal symptoms: their incidence and treatment." Am J Psychiatry 123 (1967): 886-9
- Lamont S "Acute reactions to phenothiazine derivatives." Br J Anaesth 44 (1972): 539-40
- Schumock GT, Martinez E "Acute oculogyric crisis after administration of prochlorperazine." South Med J 84 (1991): 407-8
- Baker FM, Cook P "Compazine complications: a review." J Natl Med Assoc 73 (1981): 409-12
- Boston Collaborative Drug Surveillance Program "Drug-induced extrapyramidal symptoms." JAMA 224 (1973): 889-91
- "Product Information. Prolixin (fluphenazine)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Compazine (prochlorperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Mellaril (thioridazine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- Harries JR "Oculogyric crises due to phenothiazines." Br Med J 3 (1967): 241
- "Product Information. Serentil (mesoridazine)." Boehringer-Ingelheim PROD (2001):
- "Product Information. Torecan (thiethylperazine)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Trilafon (perphenazine)." Schering Corporation PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
- "Product Information. Stelazine (trifluoperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Vesprin (triflupromazine)." Bristol-Myers Squibb PROD (2001):
- Talbert RL, Yee GC, DiPiro JT, Matzke GR, Posey LM, Wells BG "Pharmacotherapy: A Pathophysiologic Approach" Stamford, CT: Appleton & Lange (1999):
Phenothiazines (applies to Mepergan) hematologic toxicity
Moderate Potential Hazard, Moderate plausibility. Applicable conditions: Bone Marrow Depression/Low Blood Counts
Phenothiazines may infrequently cause hematologic toxicity, including agranulocytosis, thrombocytopenia, eosinophilia, aplastic anemia, purpura, granulocytopenia, and hemolytic anemia. Mild leukopenia may occur frequently with large doses over prolonged periods but is generally reversible despite continued treatment. Therapy with phenothiazines should be administered cautiously, if at all, in patients with preexisting blood dyscrasias or bone marrow suppression. Complete blood counts should be obtained regularly, and patients should be instructed to immediately report any signs or symptoms suggestive of blood dyscrasia such as fever, sore throat, local infection, bleeding, pallor, dizziness, or jaundice. Most cases of agranulocytosis have occurred between the fourth and tenth weeks of therapy.
References
- Stein P, Inwood M "Hemolytic anemia associated with chlorpromazine therapy." Can J Psychiatry 25 (1980): 659-61
- Holt R "Neuroleptic drug-induced changes in platelet levels." J Clin Psychopharmacol 4 (1984): 130-2
- Yassa R "Agranulocytosis in the course of phenothiazine therapy." J Clin Psychiatry 46 (1985): 341-3
- Zengotita H, Holt R "Neuroleptic drug-induced coagulopathy: mechanism of reaction and duration of effect." J Clin Psychiatry 47 (1986): 35-7
- Aram H "Henoch-Schonlein purpura induced by chlorpromazine." J Am Acad Dermatol 17 (1987): 139-40
- Young A, Kehoe R "Two cases of agranulocytosis on addition of a butyrophenone to a long-standing course of phenothiazine treatment." Br J Psychiatry 154 (1989): 710-12
- Ben-Yehuda A, Bloom A, Lijhovetzky G, et al. "Chlorpromazine-induced liver and bone marrow granulomas associated with agranulocytosis." Isr J Med Sci 26 (1990): 449-51
- "Product Information. Thorazine (chlorpromazine)." SmithKline Beecham PROD (2002):
- "Product Information. Phenergan (promethazine)." Wyeth-Ayerst Laboratories PROD (2001):
- Rosenthal DS, Stein GF, Santos JC "Thioridazine agranulocytosis." JAMA 200 (1967): 81-2
- Holt RJ "Fluphenazine decanoate-induced cholestatic jaundice and thrombocytopenia." Pharmacotherapy 4 (1984): 227-9
- "Product Information. Prolixin (fluphenazine)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Compazine (prochlorperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Mellaril (thioridazine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Serentil (mesoridazine)." Boehringer-Ingelheim PROD (2001):
- "Product Information. Torecan (thiethylperazine)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Trilafon (perphenazine)." Schering Corporation PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
- "Product Information. Stelazine (trifluoperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Vesprin (triflupromazine)." Bristol-Myers Squibb PROD (2001):
Phenothiazines (applies to Mepergan) liver disease
Moderate Potential Hazard, Moderate plausibility.
Phenothiazines are extensively metabolized by the liver and may accumulate in patients with hepatic impairment. In addition, the use of some phenothiazines has been associated with adverse hepatic effects including cholestatic jaundice and elevated liver enzymes, generally within the first few months of therapy. Cholestatic jaundice usually occurs between the second and fourth weeks of therapy in approximately 0.1% to 4% of all patients. Therapy with phenothiazines should be administered cautiously in patients with preexisting liver disease, liver enzyme abnormalities, or hepatitis. Liver function and urine bilirubin tests should be performed periodically during prolonged therapy, and patients should be instructed to immediately report any signs or symptoms suggestive of cholestatic jaundice such as upper abdominal pain, nausea, yellow skin, influenza-like symptoms, rash, and fever. Phenothiazine therapy should be discontinued, preferably permanently, if jaundice occurs and is attributable to the drug. Clinical recovery is usually observed within a few weeks following withdrawal of therapy, although histopathologic changes may persist for longer periods.
References
- Seeff L "Drug-induced chronic liver disease, with emphasis on chronic active hepatitis." Semin Liver Dis 1 (1981): 104-15
- Dossing M, Andreasen B "Drug-induced liver disease in Denmark." Scand J Gastroenterol 17 (1982): 205-11
- Bach N, Thung S, Schaffner F, Tobias H "Exaggerated cholestasis and hepatic fibrosis following simultaneous administration of chlorpromazine and sodium valproate." Dig Dis Sci 34 (1989): 1303-7
- Maxwell JD, Carrella M, Parkes JD, et al. "Plasma disappearance and cerebral effects of chlorpromazine in cirrhosis." Clin Sci 43 (1972): 143-51
- Whitfield LR, Kaul PN, Clark ML "Chlorpromazine metabolism IX: pharmacokinetics of chlorpromazine following oral administration in man." J Pharmacokinet Biopharm 6 (1978): 187-96
- Simpson GM, Yadalam KG, Levinson DF, et al. "Single-dose pharmacokinetics of fluphenazine after fluphenazine decanoate administration." J Clin psychopharmacol 10 (1990): 417-21
- Hu OY, Tang H-S, Sheeng T-Y, et al. "Pharmacokinetics of promazine I: disposition in patients with acute viral hepatitis B." Biopharm Drug Dispos 11 (1990): 557-68
- Taylor G, Houston JB, Shaffer J, Mawer G "Pharmacokinetics of promethazine and its sulphoxide metabolite after intravenous and oral administration to man." Br J Clin Pharmacol 15 (1983): 287-93
- "Product Information. Thorazine (chlorpromazine)." SmithKline Beecham PROD (2002):
- "Product Information. Sparine (promazine)." Wyeth-Ayerst Laboratories PROD (2001):
- Derby LE, Gutthann SP, Jick H, Dean AD "Liver disorders in patients receiving chlorpromazine or isoniazid." Pharmacotherapy 13 (1993): 353-8
- Chetty M, Moodley SV, Miller R "Important metabolites to measure in pharmacodynamic studies of chlorpromazine." Ther Drug Monit 16 (1994): 30-6
- Barancik M, Brandborg LL, Albion MJ "Thioridazine-induced cholestasis." JAMA 200 (1967): 69-70
- Reinhart MJ, Benson RM, Kwass SK, Storey WF "Suggestive evidence of hepatotoxicity concomitant with thioridazine hydrochloride use." JAMA 197 (1966): 767-9
- Snyder S "Fluphenazine jaundice. Report of a case." Am J Gastroenterol 73 (1980): 336-40
- Holt RJ "Fluphenazine decanoate-induced cholestatic jaundice and thrombocytopenia." Pharmacotherapy 4 (1984): 227-9
- Lok AS, Ng IO "Prochlorperazine-induced chronic cholestasis." J Hepatol 6 (1988): 369-73
- "Product Information. Prolixin (fluphenazine)." Bristol-Myers Squibb PROD (2001):
- Moradpour D, Altorfer J, Flury R, Greminger P, Meyenberger C, Jost R, Schmid M "Chlorpromazine-induced vanishing bile duct syndrome leading to biliary cirrhosis." Hepatology 20 (1994): 1437-41
- "Product Information. Compazine (prochlorperazine)." SmithKline Beecham PROD (2001):
- Podevin P, Biour M "Drug-induced ''allergic hepatitis''." Clin Rev Allergy Immunol 13 (1995): 223-44
- "Product Information. Mellaril (thioridazine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Serentil (mesoridazine)." Boehringer-Ingelheim PROD (2001):
- "Product Information. Torecan (thiethylperazine)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
- "Product Information. Stelazine (trifluoperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Vesprin (triflupromazine)." Bristol-Myers Squibb PROD (2001):
Phenothiazines (applies to Mepergan) NMS
Moderate Potential Hazard, Moderate plausibility. Applicable conditions: Neuroleptic Malignant Syndrome
The central dopaminergic blocking effects of phenothiazines may precipitate or aggravate a potentially fatal symptom complex known as Neuroleptic Malignant Syndrome (NMS). NMS is observed most frequently when high-potency neuroleptic agents like haloperidol or fluphenazine are administered intramuscularly but may occur with any agent possessing neuroleptic activity given for any length of time. Clinical manifestations of NMS include hyperpyrexia, muscle rigidity, altered mental status and autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis and cardiac arrhythmias). Phenothiazine therapy should not be initiated in patients with active NMS and should be immediately discontinued if currently being administered in such patients. In patients with a history of NMS, introduction or reintroduction of phenothiazines should be carefully considered, since NMS may recur.
References
- Morris H, McCormick W, Reinarz J "Neuroleptic malignant syndrome." Arch Neurol 37 (1980): 462-3
- Price W, Giannini A "A paradoxical response to chlorpromazine: a possible variant of the neuroleptic malignant syndrome." J Clin Pharmacol 23 (1983): 567-9
- Tenenbein M "The neuroleptic malignant syndrome: occurrence in a 15-year-old boy and recovery with bromocriptine therapy." Pediatr Neurosci 12 (1985): 161-4
- Caroff SN "The neuroleptic malignant syndrome." J Clin Psychiatry 41 (1980): 79-83
- "Product Information. Thorazine (chlorpromazine)." SmithKline Beecham PROD (2002):
- "Product Information. Sparine (promazine)." Wyeth-Ayerst Laboratories PROD (2001):
- Zubenko G, Pope HG, Jr "Management of a case of neuroleptic malignant syndrome with bromocriptine." Am J Psychiatry 140 (1983): 1619-20
- Granato JE, Stern BJ, Ringel A, Karim AH, Krumholz A, Coyle J, Adler S "Neuroleptic malignant syndrome: successful treatment with dantrolene and bromocriptine." Ann Neurol 14 (1983): 89-90
- Grunhaus L, Sancovici S, Rimon R "Neuroleptic malignant syndrome due to depot fluphenazine." J Clin Psychiatry 40 (1979): 99-100
- Dhib-Jalbut S, Hesselbrock R, Brott T, Silbergeld D "Treatment of the neuroleptic malignant syndrome with bromocriptine" JAMA 250 (1983): 484-5
- Caroff S, Rosenberg H, Gerber JC "Neuroleptic malignant syndrome and malignant hyperthermia" Lancet 1 (1983): 244
- Rampertaap MP "Neuroleptic malignant syndrome." South Med J 79 (1986): 331-6
- West D "Dangers of fluphenazine." Br J Psychiatry 117 (1970): 718-9
- Manser TJ, Warner JF "Neuroleptic malignant syndrome associated with prochlorperazine." South Med J 83 (1990): 73-4
- "Product Information. Prolixin (fluphenazine)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Compazine (prochlorperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Mellaril (thioridazine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Serentil (mesoridazine)." Boehringer-Ingelheim PROD (2001):
- "Product Information. Torecan (thiethylperazine)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Trilafon (perphenazine)." Schering Corporation PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
- "Product Information. Stelazine (trifluoperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Vesprin (triflupromazine)." Bristol-Myers Squibb PROD (2001):
Phenothiazines (applies to Mepergan) parkinsonism
Moderate Potential Hazard, Moderate plausibility.
The use of phenothiazines is associated with pseudo-parkinsonian symptoms such as akinesia, bradykinesia, tremors, pill-rolling motion, cogwheel rigidity, and postural abnormalities including stooped posture and shuffling gait. The onset is usually 1 to 2 weeks following initiation of therapy or an increase in dosage. Propylamino derivatives such as chlorpromazine, promazine, and triflupromazine may be more likely to induce these effects. Therapy with phenothiazines should be administered cautiously in patients with Parkinson's disease or parkinsonian symptoms.
References
- Rajput A, Rozdilsky B, Hornykiewicz O, et al. "Reversible drug-induced parkinsonism." Arch Neurol 39 (1982): 6446
- Mariani P "Adverse reactions to chlorpromazine in the treatment of migraine." Ann Emerg Med 17 (1988): 380-1
- Schwinghammer TL, Kroboth FJ, Juhl RP "Extrapyramidal reaction secondary to oral promethazine." Clin Pharm 3 (1984): 83-5
- Marcotte DB "Neuroleptics and neurologic reactions." South Med J 66 (1973): 321-4
- "Product Information. Thorazine (chlorpromazine)." SmithKline Beecham PROD (2002):
- "Product Information. Sparine (promazine)." Wyeth-Ayerst Laboratories PROD (2001):
- "Product Information. Phenergan (promethazine)." Wyeth-Ayerst Laboratories PROD (2001):
- Lamb P, Mindham RH, Ezzat MA "Letter: Parkinsonism induced by fluphenazine decanoate." Lancet 1 (1976): 484
- Curson DA, Barnes TR, Bamber RW, Platt SD, Hirsch SR, Duffy JC "Long-term depot maintenance of chronic schizophrenic out-patients: the seven year follow-up of the Medical Research Council fluphenazine/placebo trial. II. The incidence of compliance problems,side-effects, neurotic symptoms and depression" Br J Psychiatry 146 (1985): 469-74
- Oyewumi LK, Lapierre YD, Gray R, Batth S, Gelfand R "Abnormal involuntary movements in patients on long-acting neuroleptics." Prog Neuropsychopharmacol Biol Psychiatry 7 (1983): 719-23
- Sheppard C, Merlis S "Drug-induced extrapyramidal symptoms: their incidence and treatment." Am J Psychiatry 123 (1967): 886-9
- Edelstein H, Knight RT "Severe parkinsonism in two AIDS patients taking prochlorperazine." Lancet 2 (1987): 341-2
- Baker FM, Cook P "Compazine complications: a review." J Natl Med Assoc 73 (1981): 409-12
- Boston Collaborative Drug Surveillance Program "Drug-induced extrapyramidal symptoms." JAMA 224 (1973): 889-91
- "Product Information. Prolixin (fluphenazine)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Compazine (prochlorperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Mellaril (thioridazine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Serentil (mesoridazine)." Boehringer-Ingelheim PROD (2001):
- "Product Information. Torecan (thiethylperazine)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Trilafon (perphenazine)." Schering Corporation PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
- "Product Information. Stelazine (trifluoperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Vesprin (triflupromazine)." Bristol-Myers Squibb PROD (2001):
Phenothiazines (applies to Mepergan) renal dysfunction
Moderate Potential Hazard, Moderate plausibility.
Phenothiazines and their metabolites are excreted by the kidney. There are very limited data concerning the use of phenothiazines in patients with renal disease. Therapy with phenothiazines should be administered cautiously in patients with significantly impaired renal function. The manufacturers recommend periodic renal function tests for all patients during prolonged therapy.
References
- Dorson P, Crismon M "Chlorpromazine accumulation and sudden death in a patient with renal insufficiency." Drug Intell Clin Pharm 22 (1988): 776-8
- Taylor G, Houston JB, Shaffer J, Mawer G "Pharmacokinetics of promethazine and its sulphoxide metabolite after intravenous and oral administration to man." Br J Clin Pharmacol 15 (1983): 287-93
- Fabre J, Freudenreich J, de Duckert A, Pitton JS, Rudhardt M, Virieux C "Influence of renal insufficiency on the excretion of chloroquine, phenobarbital, phenothiazines and methacycline." Helv Med Acta 33 (1967): 307-16
- McAllister CJ, Scowden EB, Stone WJ "Toxic psychosis induced by phenothiazine administration in patients with chronic renal failure." Clin Nephrol 10 (1978): 191-5
- "Product Information. Thorazine (chlorpromazine)." SmithKline Beecham PROD (2002):
- "Product Information. Sparine (promazine)." Wyeth-Ayerst Laboratories PROD (2001):
- "Product Information. Prolixin (fluphenazine)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Compazine (prochlorperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Mellaril (thioridazine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Serentil (mesoridazine)." Boehringer-Ingelheim PROD (2001):
- "Product Information. Torecan (thiethylperazine)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Trilafon (perphenazine)." Schering Corporation PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
- "Product Information. Stelazine (trifluoperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Vesprin (triflupromazine)." Bristol-Myers Squibb PROD (2001):
Phenothiazines (applies to Mepergan) seizure disorders
Moderate Potential Hazard, Moderate plausibility. Applicable conditions: CNS Disorder
Phenothiazines can lower the seizure threshold and induce seizures, particularly when dosages are high or increased rapidly and during the initiation of therapy. Of the phenothiazines used in the treatment of psychosis, chlorpromazine appears to have the greatest epileptogenic potential, while fluphenazine and thioridazine have the least. Therapy with phenothiazines should be administered cautiously in patients with a history of seizures or other factors predisposing to seizures such as abnormal EEG, preexisting CNS pathology, or head trauma. Adequate anticonvulsant therapy should be maintained during administration of phenothiazines.
References
- Markowitz J, Brown R "Seizures with neuroleptics and antidepressants." Gen Hosp Psychiatry 9 (1987): 135-41
- Waterhouse RG "Epileptiform convulsions in children following premedication with Pamergan SP100." Br J Anaesth 39 (1967): 268-70
- "Product Information. Thorazine (chlorpromazine)." SmithKline Beecham PROD (2002):
- "Product Information. Sparine (promazine)." Wyeth-Ayerst Laboratories PROD (2001):
- "Product Information. Phenergan (promethazine)." Wyeth-Ayerst Laboratories PROD (2001):
- "Product Information. Prolixin (fluphenazine)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Compazine (prochlorperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Mellaril (thioridazine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Moban (molindone)." Gate Pharmaceuticals PROD (2001):
- "Product Information. Orap (pimozide)." Gate Pharmaceuticals PROD
- "Product Information. Serentil (mesoridazine)." Boehringer-Ingelheim PROD (2001):
- "Product Information. Torecan (thiethylperazine)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Trilafon (perphenazine)." Schering Corporation PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
- "Product Information. Stelazine (trifluoperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Vesprin (triflupromazine)." Bristol-Myers Squibb PROD (2001):
- Talbert RL, Yee GC, DiPiro JT, Matzke GR, Posey LM, Wells BG "Pharmacotherapy: A Pathophysiologic Approach" Stamford, CT: Appleton & Lange (1999):
Phenothiazines (applies to Mepergan) tardive dyskinesia
Moderate Potential Hazard, Moderate plausibility.
Phenothiazines may commonly precipitate symptoms of tardive dyskinesia (TD), a syndrome consisting of rhythmic involuntary movements variously involving the tongue, face, mouth, lips, jaw, and/or trunk and extremities, following chronic use of at least several months but often years. Elderly patients, particularly women, are most susceptible. Also, propylpiperazine derivatives like fluphenazine, perphenazine, prochlorperazine, and trifluoperazine may be more likely to induce this syndrome. Both the risk of developing TD and the likelihood that it will become irreversible increase with the duration and total cumulative dose of phenothiazine therapy administered. However, patients may infrequently develop symptoms after relatively brief treatment periods at low dosages. If TD occurs during phenothiazine therapy, prompt withdrawal of the offending agent or at least a lowering of the dosage should be considered. TD symptoms usually become more severe after drug discontinuation or a dosage reduction, but may gradually improve over months to years. In patients with preexisting drug-induced TD, initiating or increasing the dosage of phenothiazine therapy may temporarily mask the symptoms of TD but may eventually worsen the condition. The newer, atypical neuroleptic agents (e.g., risperidone, quetiapine, olanzapine) tend to be associated with a substantially reduced risk of inducing TD and are considered the drugs of choice in patients being treated for psychosis.
References
- Yassa R, Dimitry R "Single phenothiazines and tardive dyskinesia." J Clin Psychiatry 44 (1983): 233-4
- Mariani P "Adverse reactions to chlorpromazine in the treatment of migraine." Ann Emerg Med 17 (1988): 380-1
- Yesavage JA, Tanke ED, Sheikh JI "Tardive dyskinesia and steady-state serum levels of thiothixene." Arch Gen Psychiatry 44 (1987): 913-5
- Schwinghammer TL, Kroboth FJ, Juhl RP "Extrapyramidal reaction secondary to oral promethazine." Clin Pharm 3 (1984): 83-5
- Marcotte DB "Neuroleptics and neurologic reactions." South Med J 66 (1973): 321-4
- "Product Information. Thorazine (chlorpromazine)." SmithKline Beecham PROD (2002):
- "Product Information. Sparine (promazine)." Wyeth-Ayerst Laboratories PROD (2001):
- Csernansky JG, Grabowski K, Cervantes J, Kaplan J, Yesavage JA "Fluphenazine decanoate and tardive dyskinesia: a possible association." Am J Psychiatry 138 (1981): 1362-5
- Perenyi A, Arato M "Fluphenazine and tardive dyskinesia" Arch Gen Psychiatry 41 (1984): 727
- Mukherjee S, Rosen AM, Cardenas C, Varia V, Olarte S "Tardive dyskinesia in psychiatric outpatients: a study of prevalence and association with demographic, clinical, and drug history variables." Arch Gen Psychiatry 39 (1982): 466-9
- Kolakowska T, Williams AO, Ardern M "Tardive dyskinesia and current dose of neuroleptic drugs" Arch Gen Psychiatry 42 (1985): 925
- Glazer WM, Moore DC "The diagnosis of rapid abnormal involuntary movements associated with fluphenazine decanoate." J Nerv Ment Dis 168 (1980): 439-41
- McClelland HA, Metcalfe AV, Kerr TA, Dutta D, Watson P "Facial dyskinesia: a 16-year follow-up study" Br J Psychiatry 158 (1991): 691-6
- Curson DA, Barnes TR, Bamber RW, Platt SD, Hirsch SR, Duffy JC "Long-term depot maintenance of chronic schizophrenic out-patients: the seven year follow-up of the Medical Research Council fluphenazine/placebo trial. II. The incidence of compliance problems,side-effects, neurotic symptoms and depression" Br J Psychiatry 146 (1985): 469-74
- Yassa R, Iskandar H, Ally J "The prevalence of tardive dyskinesia in fluphenazine-treated patients." J Clin Psychopharmacol 8 (1988): 17S-20S
- Oyewumi LK, Lapierre YD, Gray R, Batth S, Gelfand R "Abnormal involuntary movements in patients on long-acting neuroleptics." Prog Neuropsychopharmacol Biol Psychiatry 7 (1983): 719-23
- Sheppard C, Merlis S "Drug-induced extrapyramidal symptoms: their incidence and treatment." Am J Psychiatry 123 (1967): 886-9
- Baker FM, Cook P "Compazine complications: a review." J Natl Med Assoc 73 (1981): 409-12
- Boston Collaborative Drug Surveillance Program "Drug-induced extrapyramidal symptoms." JAMA 224 (1973): 889-91
- "Product Information. Prolixin (fluphenazine)." Bristol-Myers Squibb PROD (2001):
- "Product Information. Compazine (prochlorperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Mellaril (thioridazine)." Sandoz Pharmaceuticals Corporation PROD (2001):
- "Product Information. Serentil (mesoridazine)." Boehringer-Ingelheim PROD (2001):
- "Product Information. Torecan (thiethylperazine)." Roxane Laboratories Inc PROD (2001):
- "Product Information. Trilafon (perphenazine)." Schering Corporation PROD (2001):
- "Product Information. Tacaryl (methdilazine)." Westwood Squibb Pharmaceutical Corporation PROD (2001):
- "Product Information. Temaril (trimeprazine)." Allergan Inc PROD (2001):
- "Product Information. Stelazine (trifluoperazine)." SmithKline Beecham PROD (2001):
- "Product Information. Vesprin (triflupromazine)." Bristol-Myers Squibb PROD (2001):
- Talbert RL, Yee GC, DiPiro JT, Matzke GR, Posey LM, Wells BG "Pharmacotherapy: A Pathophysiologic Approach" Stamford, CT: Appleton & Lange (1999):
Promethazine (applies to Mepergan) antidopaminergic effects 2
Moderate Potential Hazard, Low plausibility. Applicable conditions: Parkinsonism
Promethazine has weak central antidopaminergic activity. While its use is rarely associated with adverse effects secondary to dopaminergic blockade, large doses have produced extrapyramidal reactions. During chronic administration and/or high-dose therapy, the usual contraindications, warnings and precautions applicable to phenothiazines should be observed with promethazine.
References
- Nicholson AN "Central effects of H1 and H2 antihistamines." Aviat Space Environ Med 56 (1985): 293-8
- Schwinghammer TL, Kroboth FJ, Juhl RP "Extrapyramidal reaction secondary to oral promethazine." Clin Pharm 3 (1984): 83-5
- "Product Information. Phenergan (promethazine)." Wyeth-Ayerst Laboratories PROD (2001):
Mepergan drug interactions
There are 750 drug interactions with Mepergan (meperidine / promethazine).
Mepergan alcohol/food interactions
There is 1 alcohol/food interaction with Mepergan (meperidine / promethazine).
More about Mepergan (meperidine / promethazine)
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Drug Interaction Classification
Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit. | |
Moderately clinically significant. Usually avoid combinations; use it only under special circumstances. | |
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. | |
No interaction information available. |
Further information
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