Drug Interactions between amoxicillin / clarithromycin / omeprazole and Sinuva

MONITOR: Coadministration with potent inhibitors of CYP450 3A4 may increase the plasma concentrations of mometasone, which is primarily metabolized by the isoenzyme. In healthy subjects coadministered mometasone (400 mcg inhaled twice daily for 9 days) with the potent CYP450 3A4 inhibitor ketoconazole (200 mg orally twice daily on days 4 to 9), 4 out of 12 subjects had peak plasma concentrations of mometasone increase from less than 150 pcg/mL on day 3 before the addition of ketoconazole to more than 200 pcg/mL afterwards. Serum cortisol AUC also decreased slightly after ketoconazole was added. The clinical significance of these findings is unknown.

MANAGEMENT: The possibility of increased systemic adverse effects of mometasone should be considered during coadministration with potent CYP450 3A4 inhibitors. Some authorities advise against concomitant use unless the potential benefit outweighs the risk. If the combination cannot be avoided, the dosing times between mometasone and the CYP450 3A4 inhibitor should be separated by as much as possible. In addition, the lowest effective dosage of mometasone should be prescribed, and further adjustments made as necessary according to therapeutic response and tolerance. Alternatively, a less potent, less lipophilic, and/or shorter-acting agent such as beclomethasone may be considered. Beclomethasone is also less dependent on CYP450 3A4 metabolism. Patients should be monitored for signs and symptoms of hypercorticism such as acne, striae, thinning of the skin, easy bruising, moon facies, dorsocervical "buffalo" hump, truncal obesity, increased appetite, acute weight gain, edema, hypertension, hirsutism, hyperhidrosis, proximal muscle wasting and weakness, glucose intolerance, exacerbation of preexisting diabetes, depression, and menstrual disorders. Other systemic glucocorticoid effects may include adrenal suppression, immunosuppression, posterior subcapsular cataracts, glaucoma, bone loss, and growth retardation in children and adolescents.

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Although some in vitro data indicate synergism between macrolide antibiotics and penicillins, other in vitro data indicate antagonism. When these drugs are given together, neither has predictable therapeutic efficacy. Data are available for erythromycin, although theoretically this interaction could occur with any macrolide. Except for monitoring of the effectiveness of antibiotic therapy, no special precautions appear to be necessary.

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Clarithromycin may increase and prolong the omeprazole plasma concentration. The mechanism may be related to clarithromycin inhibition of hepatic cytochrome P450 enzymes responsible for omeprazole metabolism. Coadministration of omeprazole may result in an increase in clarithromycin and 14-(R)-hydroxyclarithromycin plasma concentrations. These increases may be due to the effect of omeprazole on gastric pH.

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