Drug Interactions between budesonide / formoterol and chlorothiazide / methyldopa
This report displays the potential drug interactions for the following 2 drugs:
- budesonide/formoterol
- chlorothiazide/methyldopa
Interactions between your drugs
methyldopa budesonide
Applies to: chlorothiazide / methyldopa and budesonide / formoterol
MONITOR: Corticosteroids may antagonize the effects of antihypertensive medications by inducing sodium and fluid retention. These effects may be more common with the natural corticosteroids (cortisone, hydrocortisone) because they have greater mineralocorticoid activity. Conversely, some calcium channel blockers such as diltiazem and verapamil may increase corticosteroid plasma levels and effects by inhibiting their clearance via CYP450 3A4 metabolism.
MANAGEMENT: Patients on prolonged (i.e., longer than about a week) or high-dose corticosteroid therapy should have blood pressure, electrolyte levels, and body weight monitored regularly, and be observed for the development of edema and congestive heart failure. The dosages of antihypertensive medications may require adjustment.
References
- "Multum Information Services, Inc. Expert Review Panel"
- Cerner Multum, Inc. "UK Summary of Product Characteristics."
chlorothiazide budesonide
Applies to: chlorothiazide / methyldopa and budesonide / formoterol
MONITOR: The concomitant use of corticosteroids and agents that deplete potassium (e.g., potassium-wasting diuretics, amphotericin B, cation exchange resins) may result in increased risk of hypokalemia. Corticosteroids can produce hypokalemia and other electrolyte disturbances via mineralocorticoid effects, the degree of which varies with the agent (from most to least potent: fludrocortisone - cortisone/hydrocortisone - prednisolone/prednisone - other glucocorticoids) and route of administration (i.e. systemic vs. local). However, large systemic doses of any corticosteroid can demonstrate these effects, particularly if given for longer than brief periods. When used pharmacologically, adrenocorticotropic agents such as corticotropin have similar mineralocorticoid activities as cortisone and hydrocortisone.
MANAGEMENT: Patients receiving potassium-depleting agents with corticosteroids should be monitored closely for development of hypokalemia, particularly if fludrocortisone or large doses of another corticosteroid or adrenocorticotropic agent is given. Potassium supplementation may be necessary. Patients should be advised to notify their physician if they experience signs of electrolyte disturbances such as weakness, lethargy, and muscle pains or cramps.
References
- Thomas TP (1984) "The complications of systemic corticosteroid therapy in the elderly." Gerontology, 30, p. 60-5
- Seale JP, Compton MR (1986) "Side-effects of corticosteroid agents." Med J Aust, 144, p. 139-42
- Morris GC, Egan JG, Jones MK (1992) "Hypokalaemic paralysis induced by bolus prednisolone in Graves' disease." Aust N Z J Med, 22, p. 312
- Powell JR (1969) "Steroid and hypokalemic myopathy after corticosteroids for ulcerative colitis. Systemic and tropical application." Am J Gastroenterol, 52, p. 425-32
- Chrousos GA, Kattah JC, Beck RW, Cleary PA (1993) "Side effects of glucocorticoid treatment. Experience of the Optic Neuritis Treatment Trial." JAMA, 269, p. 2110-2
- Thorn GW (1966) "Clinical considerations in the use of corticosteroids." N Engl J Med, 274, p. 775-81
- (2001) "Product Information. Hydeltrasol (prednisolone)." Merck & Co., Inc
- Ramsahoye BH, Davies SV, el-Gaylani N, Sandeman D, Scanlon MF (1995) "The mineralocorticoid effects of high dose hydrocortisone." BMJ, 310, p. 656-7
methyldopa formoterol
Applies to: chlorothiazide / methyldopa and budesonide / formoterol
MONITOR: Limited data suggest that methyldopa and other sympatholytics may increase or prolong the pressor effect of sympathomimetics. Hypertension may result. Data exist for phenylpropanolamine and norepinephrine.
MANAGEMENT: If these drugs must be coadministered, blood pressure should be closely monitored. Discontinuation of the sympathomimetic may be necessary if hypertension develops.
References
- McLaren EH (1976) "Severe hypertension produced by interaction of phenylpropanolamine with methyldopa and oxprenolol." Br Med J, 2, p. 283-4
- (2001) "Product Information. Allegra-D (fexofenadine-pseudoephedrine)." Chattem Consumer Products
chlorothiazide formoterol
Applies to: chlorothiazide / methyldopa and budesonide / formoterol
MONITOR: Coadministration with beta-2 adrenergic agonists may potentiate the hypokalemic effects of potassium-wasting diuretics. Beta-2 agonists can cause clinically significant but usually transient decreases in serum potassium concentrations. Since QT prolongation is a possible side effect of beta-2 agonists, exacerbation of hypokalemia may increase the risk of torsade de pointes and other serious arrhythmias. The interaction may be more likely with systemic or nebulized formulations of beta-2 agonists, high dosages of inhaled beta-2 agonists, or concomitant theophylline or corticosteroid therapy.
MANAGEMENT: Caution is advised when beta-2 agonists are used with potassium-wasting diuretics. Serum potassium level and cardiovascular status should be monitored, especially if the beta-2 agonist is administered systemically or by nebulizer. Patients should be advised to notify their physician if they experience potential signs and symptoms of hypokalemia such as fatigue, weakness, myalgia, muscle cramps, numbness, tingling, abdominal pain, constipation, palpitation, and irregular heartbeat.
References
- Lipworth BJ, McDevitt DG, Struthers AD (1989) "Prior treatment with diuretic augments the hypokalemic and electrocardiographic effects of inhaled albuterol." Am J Med, 86, p. 653-7
- (2002) "Product Information. Proventil (albuterol)." Schering Corporation
- (2001) "Product Information. Brethaire (terbutaline)." Novartis Pharmaceuticals
- (2001) "Product Information. Combivent (albuterol-ipratropium)." Boehringer-Ingelheim
- (2006) "Product Information. Brovana (arformoterol)." Sepracor Inc
- (2011) "Product Information. Arcapta Neohaler (indacaterol)." Novartis Pharmaceuticals
- (2013) "Product Information. Breo Ellipta (fluticasone-vilanterol)." GlaxoSmithKline
- (2014) "Product Information. Striverdi Respimat (olodaterol)." Boehringer Ingelheim
budesonide formoterol
Applies to: budesonide / formoterol and budesonide / formoterol
Although they are often combined in clinical practice, the concomitant use of beta-2 adrenergic agonists and corticosteroids may result in additive hypokalemic effects. Since beta-2 agonists can sometimes cause QT interval prolongation, the development of hypokalemia may potentiate the risk of ventricular arrhythmias including torsade de pointes. However, clinical data are limited, and the potential significance is unknown. Patients who are receiving systemic or nebulized formulations of beta-2 agonists, high dosages of inhaled beta-2 agonists, or systemic corticosteroid therapy may be at a greater risk of developing hypokalemia.
References
- (2001) "Product Information. Foradil (formoterol)." Novartis Pharmaceuticals
- Cerner Multum, Inc. "UK Summary of Product Characteristics."
- Cerner Multum, Inc. "Australian Product Information."
- Agencia EspaƱola de Medicamentos y Productos Sanitarios Healthcare (2008) Centro de informaciĆ³n online de medicamentos de la AEMPS - CIMA. https://cima.aemps.es/cima/publico/home.html
Drug and food interactions
budesonide food
Applies to: budesonide / formoterol
GENERALLY AVOID: Grapefruit juice may increase the plasma concentrations and systemic effects of orally administered budesonide. The proposed mechanism is inhibition of CYP450 3A4-mediated first-pass metabolism in the gut wall by certain compounds present in grapefruits. According to the manufacturer, the systemic exposure of oral budesonide approximately doubles after extensive intake of grapefruit juice.
MANAGEMENT: Patients receiving budesonide should avoid the regular consumption of grapefruits and grapefruit juice to prevent undue increases in plasma budesonide levels and systemic effects.
References
- (2001) "Product Information. Entocort (budesonide)." AstraZeneca Pharma Inc
methyldopa food
Applies to: chlorothiazide / methyldopa
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
- Sternbach H (1991) "Fluoxetine-associated potentiation of calcium-channel blockers." J Clin Psychopharmacol, 11, p. 390-1
- Shook TL, Kirshenbaum JM, Hundley RF, Shorey JM, Lamas GA (1984) "Ethanol intoxication complicating intravenous nitroglycerin therapy." Ann Intern Med, 101, p. 498-9
- Feder R (1991) "Bradycardia and syncope induced by fluoxetine." J Clin Psychiatry, 52, p. 139
- Ellison JM, Milofsky JE, Ely E (1990) "Fluoxetine-induced bradycardia and syncope in two patients." J Clin Psychiatry, 51, p. 385-6
- 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
- Cerner Multum, Inc. "Australian Product Information."
- Pacher P, Kecskemeti V (2004) "Cardiovascular side effects of new antidepressants and antipsychotics: new drugs, old concerns?" Curr Pharm Des, 10, p. 2463-75
- Andrews C, Pinner G (1998) "Postural hypotension induced by paroxetine." BMJ, 316, p. 595
chlorothiazide food
Applies to: chlorothiazide / methyldopa
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
- Sternbach H (1991) "Fluoxetine-associated potentiation of calcium-channel blockers." J Clin Psychopharmacol, 11, p. 390-1
- Shook TL, Kirshenbaum JM, Hundley RF, Shorey JM, Lamas GA (1984) "Ethanol intoxication complicating intravenous nitroglycerin therapy." Ann Intern Med, 101, p. 498-9
- Feder R (1991) "Bradycardia and syncope induced by fluoxetine." J Clin Psychiatry, 52, p. 139
- Ellison JM, Milofsky JE, Ely E (1990) "Fluoxetine-induced bradycardia and syncope in two patients." J Clin Psychiatry, 51, p. 385-6
- 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
- Cerner Multum, Inc. "Australian Product Information."
- Pacher P, Kecskemeti V (2004) "Cardiovascular side effects of new antidepressants and antipsychotics: new drugs, old concerns?" Curr Pharm Des, 10, p. 2463-75
- Andrews C, Pinner G (1998) "Postural hypotension induced by paroxetine." BMJ, 316, p. 595
methyldopa food
Applies to: chlorothiazide / methyldopa
ADJUST DOSING INTERVAL: The oral bioavailability and pharmacologic effects of methyldopa may be decreased during concurrent administration with iron-containing products. The proposed mechanism is chelation of methyldopa by the iron cation, forming an insoluble complex that is poorly absorbed from the gastrointestinal tract. In one study, five hypertensive patients receiving chronic methyldopa therapy (250 mg to 1500 mg daily) all had elevated blood pressure following the addition of ferrous sulfate 325 mg three times daily for 2 weeks. The systolic pressure had increased by more than 15 mmHg in three of the patients and the diastolic pressure increased by more than 10 mmHg in two. Blood pressure returned to baseline within 7 days of discontinuing the iron. In 12 normal subjects, administration of methyldopa 500 mg with ferrous sulfate 325 mg or ferrous gluconate 600 mg resulted in an 88% and 79% reduction, respectively, in the renal excretion of unmetabolized, free methyldopa compared to administration of methyldopa alone. In another study, administration of ferrous sulfate simultaneously with methyldopa reduced the bioavailability of methyldopa by 83%, while administration one hour or two hours before methyldopa reduced its bioavailability by 55% and 42%, respectively.
MANAGEMENT: Until more information is available, patients receiving methyldopa in combination with iron-containing products should be advised to separate the times of administration by as much as possible. Patients should be monitored closely for altered hypertensive effect and methyldopa dosage increased as necessary. Selection of an alternative antihypertensive therapy may be necessary.
References
- Campbell N, Paddock V, Sundaram R (1988) "Alteration of methyldopa absorption, metabolism, and blood pressure control caused by ferrous sulfate and ferrous gluconate." Clin Pharmacol Ther, 43, p. 381-6
- Campbell NR, Campbell RR, Hasinoff BB (1990) "Ferrous sulfate reduces methyldopa absorption: methyldopa: iron complex formation as a likely mechanism." Clin Invest Med, 6, p. 329-32
- Campbell NR, Hasinoff BB (1991) "Iron supplements: a common cause of drug interactions." Br J Clin Pharmacol, 31, p. 251-5
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
Drug Interaction Classification
Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit. | |
Moderately clinically significant. Usually avoid combinations; use it only under special circumstances. | |
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. | |
No interaction information available. |
Further information
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