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Drug Interactions between Atapryl and Imitrex Statdose

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

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Moderate

selegiline SUMAtriptan

Applies to: Atapryl (selegiline) and Imitrex Statdose (sumatriptan)

MONITOR: Coadministration of selegiline with 5-HT1 receptor agonists may be associated with a theoretical risk of serotonin syndrome. The proposed mechanism involves an additive pharmacodynamic effect resulting from inhibition of serotonin metabolism and stimulation of 5-HT1A receptors. However, there have been no published reports of an interaction in the medical literature, and the risk appears to be quite low based on available evidence and known pharmacology of these agents. As a class, 5-HT1 receptor agonists have rarely been associated with development of serotonin syndrome, and the reports that have been published generally describe concomitant use with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs)--agents that are well known causes of serotonin syndrome. The paucity of reported cases is consistent with the fact that 5-HT1 receptor agonists have the greatest affinity for 5-HT1D and 5-HT1B receptors, whereas serotonin syndrome is thought to result from hyperstimulation of brainstem 5-HT1A and 2A receptors. The 5-HT1 agonists that are currently marketed have demonstrated only modest affinity for 5-HT1A receptors and little to no affinity for 5-HT2A receptors. With respect to selegiline, it is considered a monoamine oxidase (MAO)-B inhibitor and does not affect the pharmacokinetics of 5-HT1 receptor agonists that are metabolized by MAO-A such as rizatripan, sumatriptan, and zolmitriptan. It is also not expected to cause serotonin syndrome when used at dosages recommended for the treatment of Parkinson's disease. However, MAO-B selectivity may be reduced with increasing dosages and some antidepressant dosages, which could theoretically increase the risk of serotonin syndrome when combined with other serotonergic agents.

MANAGEMENT: Caution is advisable when 5-HT1 receptor agonists are used with selegiline, particularly at dosages higher than that recommended for the treatment of Parkinson's disease. Patients should be monitored for symptoms of the serotonin syndrome, which may include mental status changes such as irritability, altered consciousness, confusion, hallucinations, and coma; autonomic dysfunction such as tachycardia, hyperthermia, diaphoresis, shivering, blood pressure lability, and mydriasis; neuromuscular abnormalities such as hyperreflexia, myoclonus, tremor, rigidity, and ataxia; and gastrointestinal symptoms such as abdominal cramping, nausea, vomiting, and diarrhea. If serotonin syndrome develops or is suspected during the course of therapy, all serotonergic agents should be discontinued immediately and supportive care rendered as necessary. Moderately ill patients may also benefit from the administration of a serotonin antagonist (e.g., cyproheptadine, chlorpromazine). Severe cases should be managed under consultation with a toxicologist and may require sedation, neuromuscular paralysis, intubation, and mechanical ventilation in addition to the other measures.

References

  1. Nierenberg DW, Semprebon M (1993) "The central nervous system serotonin syndrome." Clin Pharmacol Ther, 53, p. 84-8
  2. Sternbach H (1991) "The serotonin syndrome." Am J Psychiatry, 148, p. 705-13
  3. (2001) "Product Information. Eldepryl (selegiline)." Somerset Pharmaceuticals Inc
  4. (2001) "Product Information. Zomig (zolmitriptan)." Astra-Zeneca Pharmaceuticals
  5. Mills KC (1997) "Serotonin syndrome: A clinical update." Crit Care Clin, 13, p. 763
  6. Gardner DM, Lynd LD (1998) "Sumatriptan contraindications and the serotonin syndrome." Ann Pharmacother, 32, p. 33-8
  7. Mathew NT, Tietjen GE, Lucker C (1996) "Serotonin syndrome complicating migraine pharmacotherapy." Cephalalgia, 16, p. 323-7
  8. Martin TG (1996) "Serotonin syndrome." Ann Emerg Med, 28, p. 520-6
  9. Boyer EW, Shannon M (2005) "The serotonin syndrome." N Engl J Med, 352, p. 1112-20
  10. (2006) "Product Information. Emsam (selegiline)." Bristol-Myers Squibb
  11. (2006) "Product Information. Zelapar (selegiline)." Valeant Pharmaceuticals
  12. Shapiro RE, Tepper SJ (2007) "The serotonin syndrome, triptans, and the potential for drug-drug interactions." Headache, 47, p. 266-9
View all 12 references

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Drug and food interactions

Major

selegiline food

Applies to: Atapryl (selegiline)

GENERALLY AVOID: Foods that contain large amounts of tyramine may precipitate a hypertensive crisis in patients treated with monoamine oxidase inhibitors (MAOIs). The mechanism is inhibition of MAO-A, the enzyme responsible for metabolizing exogenous amines such as tyramine in the gut and preventing them from being absorbed intact. Once absorbed, tyramine is metabolized to octopamine, a substance that is believed to displace norepinephrine from storage granules. Although selegiline is considered a selective inhibitor of MAO-B, the selectivity may not be absolute even at recommended dosages. Rare cases of hypertensive reactions associated with ingestion of tyramine-containing foods have been reported in patients taking the recommended daily oral dose of selegiline. Data for transdermal selegiline indicate that the 6 mg/24 hour dosage may be given safely without dietary restrictions. However, limited data are available for higher dosages.

MANAGEMENT: Patients treated with oral selegiline and transdermal selegiline (greater than 6 mg/24 hour) should preferably avoid consumption of products that contain large amounts of amines and protein foods in which aging or breakdown of protein is used to increase flavor. These foods include cheese (particularly strong, aged or processed cheeses), sour cream, wine (particularly red wine), champagne, beer, pickled herring, anchovies, caviar, shrimp paste, liver (particularly chicken liver), dry sausage, salamis, figs, raisins, bananas, avocados, chocolate, soy sauce, bean curd, sauerkraut, yogurt, papaya products, meat tenderizers, fava bean pods, protein extracts, yeast extracts, and dietary supplements. Caffeine may also precipitate hypertensive crisis so its intake should be minimized as well. At least 14 days should elapse following discontinuation of selegiline therapy before these foods may be consumed. Specially designed reference materials and dietary consultation are recommended so that an appropriate and safe diet can be planned. Patients should also be advised to promptly seek medical attention if they experience potential signs and symptoms of a hypertensive crisis such as severe headache, visual disturbances, difficulty thinking, stupor or coma, seizures, chest pain, unexplained nausea or vomiting, and stroke-like symptoms. The recommended dosages of selegiline should not be exceeded, as it can increase the risk of nonselective MAO inhibition and a hypertensive crisis.

References

  1. Goldberg LI (1964) "Monoamine oxidase inhibitors: adverse reactions and possible mechanisms." JAMA, 190, p. 456-62
  2. Nuessle WF, Norman FC, Miller HE (1965) "Pickled herring and tranylcypromine reaction." JAMA, 192, p. 142-3
  3. Sweet RA, Liebowitz MR, Holt CS, Heimberg RG (1991) "Potential interactions between monoamine oxidase inhibitors and prescribed dietary supplements." J Clin Psychopharmacol, 11, p. 331-2
  4. McGrath PJ, Stewart JW, Quitkin FM (1989) "A possible L-deprenyl induced hypertensive reaction." J Clin Psychopharmacol, 9, p. 310-1
  5. (2001) "Product Information. Eldepryl (selegiline)." Somerset Pharmaceuticals Inc
  6. Lefebvre H, Noblet C, Morre N, Wolf LM (1995) "Pseudo-phaeochromocytoma after multiple drug interactions involving the selective monoamine oxidase inhibitor selegiline." Clin Endocrinol (Oxf), 42, p. 95-8
  7. Zetin M, Plon L, DeAntonio M (1987) "MAOI reaction with powdered protein dietary supplement." J Clin Psychiatry, 48, p. 499
  8. Domino EF, Selden EM (1984) "Red wine and reactions." J Clin Psychopharmacol, 4, p. 173-4
  9. Tailor SA, Shulman KI, Walker SE, Moss J, Gardner D (1994) "Hypertensive episode associated with phenelzine and tap beer--a reanalysis of the role of pressor amines in beer." J Clin Psychopharmacol, 14, p. 5-14
  10. Pohl R, Balon R, Berchou R (1988) "Reaction to chicken nuggets in a patient taking an MAOI." Am J Psychiatry, 145, p. 651
  11. Ito D, Amano T, Sato H, Fukuuchi Y (2001) "Paroxysmal hypertensive crises induced by selegiline in a patient with Parkinson's disease." J Neurol, 248, p. 533-4
  12. (2006) "Product Information. Emsam (selegiline)." Bristol-Myers Squibb
View all 12 references

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Moderate

selegiline food

Applies to: Atapryl (selegiline)

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

MANAGEMENT: Patients receiving CNS-active agents should be advised to avoid or limit consumption of alcohol. Ambulatory patients should be counseled against driving, operating machinery, or engaging in potentially hazardous activities requiring 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. Cerner Multum, Inc. "UK Summary of Product Characteristics."
  4. (2012) "Product Information. Fycompa (perampanel)." Eisai Inc
  5. (2015) "Product Information. Rexulti (brexpiprazole)." Otsuka American Pharmaceuticals Inc
View all 5 references

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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.

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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.

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