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Drug Interactions between Altace and lithium

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

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Interactions between your drugs

Major

lithium ramipril

Applies to: lithium and Altace (ramipril)

MONITOR CLOSELY: Coadministration with angiotensin converting enzyme (ACE) inhibitors may increase serum lithium concentrations and the risk for lithium toxicity. Several mechanisms may be involved, one of which is reduced renal lithium clearance due to natriuresis secondary to the inhibition of aldosterone and angiotensin II by ACE inhibitors. The combination may also cause renal dysfunction secondary to volume depletion during chronic therapy, which can further impair lithium clearance. The interaction was suspected in cases of lithium toxicity that occurred up to several weeks after the initiation of ACE inhibitor therapy. A retrospective study of 20 patients also found that addition of an ACE inhibitor to stable lithium therapy resulted in a mean 26% decrease in lithium clearance and a 35% increase in steady-state serum lithium concentrations. The average decline in lithium clearance was less in patients under 50 years of age than in older patients (13% vs. 31%). Four of the patients also demonstrated symptoms consistent with lithium toxicity and required dosage reduction or drug discontinuation. In contrast, a pharmacokinetic study found no significant effect of enalapril (5 mg twice a day for 10 days) on the steady-state serum lithium levels of 9 healthy volunteers receiving lithium 450 mg every 12 hours. Thus, it appears the interaction may not be completely predictable and may depend on factors such as dosages of the drugs, duration of therapy, age, and underlying medical conditions such as congestive heart failure or renal impairment. In addition, the interaction may be exacerbated by sodium restriction, dehydration, or concomitant use of diuretics or nonsteroidal anti-inflammatory drugs (NSAIDs).

MANAGEMENT: Given the narrow therapeutic index of lithium, caution is advised during coadministration with ACE inhibitors, particularly in the elderly or patients with other risk factors (e.g., sodium restriction, renal impairment, congestive heart failure, dehydration, concomitant use of diuretics or NSAIDs). Pharmacologic response and serum lithium levels should be monitored more closely whenever an ACE inhibitor is added to or withdrawn from therapy, and the lithium dosage adjusted as necessary. Empiric reductions of both drugs may be appropriate during initial therapy. Renal function should also be monitored regularly. Patients should be advised to seek medical attention if they experience potential signs and symptoms of lithium toxicity such as drowsiness, dizziness, confusion, muscle weakness, vomiting, diarrhea, polydipsia, polyuria, tinnitus, tremor, ataxia, and blurred vision.

References

  1. Correa FJ, Eiser AR (1992) "Angiotensin-converting enzyme inhibitors and lithium toxicity." Am J Med, 93, p. 108-9
  2. Simon G (1988) "Combination angiotensin converting enzyme inhibitor/lithium therapy contraindicated in renal disease." Am J Med, 85, p. 893-4
  3. DasGupta K, Jefferson JW, Kobak KA, Greist JH (1992) "The effect of enalapril on serum lithium levels in healthy men." J Clin Psychiatry, 53, p. 398-400
  4. Douste-Blazy P, Rostin M, Livarek B, et al. (1986) "Angiotensin converting enzyme inhibitors and lithium treatment." Lancet, 1, p. 1448
  5. Griffin JH, Hahn SM (1991) "Lisinopril-induced lithium toxicity." Drug Intell Clin Pharm, 25, p. 101
  6. Navis GJ, de Jong PE, de Zeeuw D (1989) "Volume homeostasis, angiotensin converting enzyme inhibition, and lithium therapy." Am J Med, 86, p. 621
  7. Baldwin CM, Safferman AZ (1990) "A case of lisinopril-induced lithium toxicity." DICP, 24, p. 946-7
  8. (2002) "Product Information. Eskalith (lithium)." SmithKline Beecham
  9. Lehmann K, Ritz E (1995) "Angiotensin-converting enzyme inhibitors may cause renal dysfunction in patients on long-term lithium treatment." Am J Kidney Dis, 25, p. 82-7
  10. Finley PR, Warner MD, Peabody CA (1995) "Clinical relevance of drug interactions with lithium." Clin Pharmacokinet, 29, p. 172-91
  11. Finley PR, Obrien JG, Coleman RW (1996) "Lithium and angiotensin-converting enzyme inhibitors: evaluation of a potential interaction." J Clin Psychopharmacol, 16, p. 68-71
  12. Shionoiri H (1993) "Pharmacokinetic drug interactions with ACE inhibitors." Clin Pharmacokinet, 25, p. 20-58
  13. Alderman CP, Lindsay KS (1996) "Increased serum lithium concentration secondary to treatment with tiaprofenic acid and fosinopril." Ann Pharmacother, 30, p. 1411-3
  14. Vipond AJ, Bakewell S, Telford R, Nicholls AJ (1996) "Lithium toxicity." Anaesthesia, 51, p. 1156-8
View all 14 references

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Drug and food interactions

Moderate

lithium food

Applies to: lithium

GENERALLY AVOID: Alcohol may potentiate some of the pharmacologic effects of CNS-active agents. Use in combination may result in additive central nervous system depression and/or impairment of judgment, thinking, and psychomotor skills.

MANAGEMENT: Patients receiving CNS-active agents should be warned of this interaction and advised to avoid or limit consumption of alcohol. Ambulatory patients should be counseled to avoid hazardous activities requiring complete mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.

References

  1. Warrington SJ, Ankier SI, Turner P (1986) "Evaluation of possible interactions between ethanol and trazodone or amitriptyline." Neuropsychobiology, 15, p. 31-7
  2. Gilman AG, eds., Nies AS, Rall TW, Taylor P (1990) "Goodman and Gilman's the Pharmacological Basis of Therapeutics." New York, NY: Pergamon Press Inc.
  3. (2012) "Product Information. Fycompa (perampanel)." Eisai Inc
  4. (2015) "Product Information. Rexulti (brexpiprazole)." Otsuka American Pharmaceuticals Inc
View all 4 references

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Moderate

ramipril food

Applies to: Altace (ramipril)

GENERALLY AVOID: Moderate-to-high dietary intake of potassium can cause hyperkalemia in some patients who are using angiotensin converting enzyme (ACE) inhibitors. In some cases, affected patients were using a potassium-rich salt substitute. ACE inhibitors can promote hyperkalemia through inhibition of the renin-aldosterone-angiotensin (RAA) system.

MANAGEMENT: It is recommended that patients who are taking ACE inhibitors be advised to avoid moderately high or high potassium dietary intake. Particular attention should be paid to the potassium content of salt substitutes.

References

  1. (2002) "Product Information. Vasotec (enalapril)." Merck & Co., Inc
  2. Good CB, McDermott L (1995) "Diet and serum potassium in patients on ACE inhibitors." JAMA, 274, p. 538
  3. Ray K, Dorman S, Watson R (1999) "Severe hyperkalaemia due to the concomitant use of salt substitutes and ACE inhibitors in hypertension: a potentially life threatening interaction." J Hum Hypertens, 13, p. 717-20

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Moderate

ramipril food

Applies to: Altace (ramipril)

MONITOR: Many psychotherapeutic and CNS-active agents (e.g., anxiolytics, sedatives, hypnotics, antidepressants, antipsychotics, opioids, alcohol, muscle relaxants) exhibit hypotensive effects, especially during initiation of therapy and dose escalation. Coadministration with antihypertensives and other hypotensive agents, in particular vasodilators and alpha-blockers, may result in additive effects on blood pressure and orthostasis.

MANAGEMENT: Caution and close monitoring for development of hypotension is advised during coadministration of these agents. Some authorities recommend avoiding alcohol in patients receiving vasodilating antihypertensive drugs. Patients should be advised to avoid rising abruptly from a sitting or recumbent position and to notify their physician if they experience dizziness, lightheadedness, syncope, orthostasis, or tachycardia.

References

  1. Sternbach H (1991) "Fluoxetine-associated potentiation of calcium-channel blockers." J Clin Psychopharmacol, 11, p. 390-1
  2. Shook TL, Kirshenbaum JM, Hundley RF, Shorey JM, Lamas GA (1984) "Ethanol intoxication complicating intravenous nitroglycerin therapy." Ann Intern Med, 101, p. 498-9
  3. Feder R (1991) "Bradycardia and syncope induced by fluoxetine." J Clin Psychiatry, 52, p. 139
  4. Ellison JM, Milofsky JE, Ely E (1990) "Fluoxetine-induced bradycardia and syncope in two patients." J Clin Psychiatry, 51, p. 385-6
  5. Rodriguez de la Torre B, Dreher J, Malevany I, et al. (2001) "Serum levels and cardiovascular effects of tricyclic antidepressants and selective serotonin reuptake inhibitors in depressed patients." Ther Drug Monit, 23, p. 435-40
  6. Cerner Multum, Inc. "Australian Product Information."
  7. Pacher P, Kecskemeti V (2004) "Cardiovascular side effects of new antidepressants and antipsychotics: new drugs, old concerns?" Curr Pharm Des, 10, p. 2463-75
  8. Andrews C, Pinner G (1998) "Postural hypotension induced by paroxetine." BMJ, 316, p. 595
View all 8 references

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Moderate

lithium food

Applies to: lithium

MONITOR: One study has suggested that caffeine withdrawal may significantly increase blood lithium levels. The mechanism may be involve reversal of a caffeine-induced increase in renal lithium excretion.

MANAGEMENT: When caffeine is eliminated from the diet of lithium-treated patients, caution should be exercised. When caffeine consumption is decreased, close observation for evidence of lithium toxicity and worsening of the psychiatric disorder is recommended. Patients should be advised to notify their physician if they experience symptoms of possible lithium toxicity such as drowsiness, dizziness, weakness, ataxia, tremor, vomiting, diarrhea, thirst, blurry vision, tinnitus, or increased urination.

References

  1. Mester R, Toren P, Mizrachi I, Wolmer L, Karni N, Weizman A (1995) "Caffeine withdrawal increases lithium blood levels." Biol Psychiatry, 37, p. 348-50

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Therapeutic duplication warnings

No warnings were found for your selected drugs.

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

See also

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Drug Interaction Classification

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

Further information

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