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Drug Interactions between astemizole and conivaptan

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

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Interactions between your drugs

Major

astemizole conivaptan

Applies to: astemizole and conivaptan

GENERALLY AVOID: Coadministration with conivaptan may significantly increase the plasma concentrations of astemizole and terfenadine. The mechanism is conivaptan inhibition of CYP450 3A4, the isoenzyme responsible for the metabolic clearance of these antihistamines. Although the interaction has not been specifically studied, high plasma levels of astemizole and terfenadine (e.g., due to overdose or interaction with other potent 3A4 inhibitors such as macrolide antibiotics and azole antifungal agents) have been associated with prolongation of the QT interval on the ECG; ventricular arrhythmias including ventricular tachycardia, ventricular fibrillation, and torsade de pointes; cardiac arrest; and sudden death. In pharmacokinetic studies with other drugs that are primarily metabolized by CYP450 3A4 such as midazolam, simvastatin, and amlodipine, conivaptan has increased systemic exposure (AUC) by 2- to 3-fold.

MANAGEMENT: Given the potential for serious and life-threatening adverse cardiac events associated with increased plasma levels of astemizole and terfenadine, use of these agents in patients treated with conivaptan should be avoided. Loratadine, cetirizine, or fexofenadine may be safer alternatives during therapy with conivaptan.

References (28)
  1. Honig PK, Woosley RL, Zamani K, Conner DP, Cantilena LR Jr (1992) "Changes in the pharmacokinetics and electrocardiographic pharmacodynamics of terfenadine with concomitant administration of erythromycin." Clin Pharmacol Ther, 52, p. 231-8
  2. Zimmermann M, Duruz H, Guinand O, et al. (1992) "Torsades de Pointes after treatment with terfenadine and ketoconazole." Eur Heart J, 13, p. 1002-3
  3. Mathews DR, McNutt B, Okerholm R, et al. (1991) "Torsades de pointes occurring in association with terfenadine use." JAMA, 266, p. 2375-6
  4. Honig PK, Wortham DC, Zamani K, et al. (1993) "Terfenadine-ketoconazole interaction: pharmacokinetic and electrocardiographic consequences." JAMA, 269, p. 1513-8
  5. Pohjola-Sintonen S, Viitasalo M, Toivonene L, Neuvonen P (1993) "Torsades de pointes after terfenadine-itraconazole interaction." BMJ, 306, p. 186
  6. Craft TM (1986) "Torsade de pointes after astemizole overdose." Br Med J, 292, p. 660
  7. Snook J, Boothman-Burrell D, Watkins J, Colin-Jones D (1988) "Torsade de pointes ventricular tachycardia associated with astemizole overdose." Br J Clin Pract, 42, p. 257-9
  8. Saviuc P, Danel V, Dixmerias F (1993) "Prolonged QT interval and torsade de pointes following astemizole overdose." J Toxicol Clin Toxicol, 31, p. 121-5
  9. Hasan RA, Zureikat GY, Nolan BM (1993) "Torsade de pointes associated with astemizole overdose treated with magnesium sulfate." Pediatr Emerg Care, 9, p. 23-5
  10. Crane JK, Shih HT (1993) "Syncope and cardiac arrhythmia due to an interaction between itraconazole and terfenadine." Am J Med, 95, p. 445-6
  11. Biglin KE, Faraon MS, Constance TD, Lieh-Lai M (1994) "Drug-induced torsades de pointes: a possible interaction of terfenadine and erythromycin." Ann Pharmacother, 28, p. 282
  12. Honig PK, Wortham DC, Hull R, Zamani K, Smith JE, Cantilena LR (1993) "Itraconazole affects single-dose terfenadine pharmacokinetics and cardiac repolarization pharmacodynamics." J Clin Pharmacol, 33, p. 1201-6
  13. Rao KA, Adlakha A, Vermaansil B, Meloy TD, Stanton MS (1994) "Torsades de pointes ventricular tachycardia associated with overdose of astemizole." Mayo Clin Proc, 69, p. 589-93
  14. Kivisto KT, Neuvonen PJ, Klotz U (1994) "Inhibition of terfenadine metabolism - pharmacokinetic and pharmacodynamic consequences." Clin Pharmacokinet, 27, p. 1-5
  15. Smith SJ (1994) "Cardiovascular toxicity of antihistamines." Otolaryngol Head Neck Surg, 111 Suppl, p. 348-54
  16. Paris DG, Parente TF, Bruschetta HR, Guzman E, Niarchos AP (1994) "Torsades-de-pointes induced by erythromycin and terfenadine." Am J Emerg Med, 12, p. 636-8
  17. Ng PW, Chan WK, Chan TYK (1996) "Torsade de pointes during the concomitant use of terfenadine and cimetidine." Aust N Z J Med, 26, p. 120-1
  18. Heidemann SM, Sarnaik AP (1996) "Arrhythmias after astemizole overdose." Pediatr Emerg Care, 12, p. 102-4
  19. Woosley RL (1996) "Cardiac actions of antihistamines." Annu Rev Pharmacol Toxicol, 36, p. 233-52
  20. Hey JA, Delprado M, Egan RW, Kreutner W (1996) "Terfenadine, astemizole, and ebastine produce QTc interval prolongation in an experimental model predictive of adverse clinical ECG effects." Ann Allergy Asthma Immunol, 76, p. 476
  21. Vorperian VR, Zhou ZF, Mohammad S, Hoon TJ, Studenik C, January CT (1996) "Torsade de pointes with an antihistamine metabolite: potassium channel blockade with desmethylastemizole." J Am Coll Cardiol, 28, p. 1556-61
  22. Tsai WC, Tsai LM, Chen JH (1997) "Combined use of astemizole and ketoconazole resulting in torsade de pointes." J Formos Med Assoc, 96, p. 144-6
  23. Ament PW, Paterson A (1997) "Drug interactions with the nonsedating antihistamines." Am Fam Physician, 56, p. 223
  24. Rankin AC (1997) "Non-sedating antihistamines and cardiac arrhythmia." Lancet, 350, p. 1115-6
  25. Gonzalez MA, Estes KS (1998) "Pharmacokinetic overview of oral second-generation H-1 antihistamines." Int J Clin Pharmacol Ther, 36, p. 292-300
  26. Dresser GK, Spence JD, Bailey DG (2000) "Pharmacokinetic-pharmacodynamic consequences and clinical relevance of cytochrome P450 3A4 inhibition." Clin Pharmacokinet, 38, p. 41-57
  27. DuBuske LM (1999) "Second-generation antihistamines: the risk of ventricular arrhythmias." Clin Ther, 21, p. 281-95
  28. (2006) "Product Information. Vaprisol (conivaptan)." Cumberland Pharmaceuticals Inc

Drug and food interactions

Major

astemizole food

Applies to: astemizole

GENERALLY AVOID: Some beverages such as tonic water contain varying amounts of quinine. Coadministration of a single 430 mg dose of quinine has been shown to increase plasma concentrations of astemizole and its metabolite, desmethylastemizole. Elevated levels of these agents may cause a prolongation of the electrocardiographic QT interval and potentially fatal ventricular arrhythmias. Although pharmacokinetic data have indicated that the amounts of quinine in beverages (up to 80 mg quinine in 32 oz of tonic water) are not sufficient to produce a significant effect, the potential for an interaction exists if large amounts of tonic water are ingested. Also, grapefruit juice has been shown to inhibit CYP450 enzymes, which may lead to increased serum astemizole concentrations. The risk of life-threatening ventricular arrhythmias may be increased.

MANAGEMENT: Patients should be counseled to limit consumption of quinine-containing beverages and avoid grapefruit juice while they are taking astemizole.

References (1)
  1. (2002) "Product Information. Hismanal (astemizole)." Janssen Pharmaceuticals

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.

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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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