Drug Interactions between amoxicillin / clarithromycin / vonoprazan and rivastigmine

MONITOR: Acetylcholinesterase inhibitors may have vagotonic effects on the sinoatrial and atrioventricular nodes, which occasionally manifest as bradycardia or heart block (<2%). Because bradycardia is a risk factor for torsade de pointes, a theoretical risk exists when combined with agents that prolong the QT interval. In general, the risk of an individual agent or a combination of agents causing ventricular arrhythmia in association with QT prolongation is largely unpredictable but may be increased by certain underlying risk factors including, but not limited to congenital long QT syndrome, cardiac disease, and electrolyte disturbances (e.g., hypokalemia, hypomagnesemia). In addition, the extent of drug-induced QT prolongation may vary depending on the dosage(s) and specific drug(s) involved.

MANAGEMENT: Caution is advised when acetylcholinesterase inhibitors are used with drugs that can prolong the QT interval. Patients should be monitored for bradycardia, atrioventricular block and syncope, and advised to seek medical attention if they experience dizziness, lightheadedness, fainting, shortness of breath, or slow or irregular heartbeat.

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.