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Drug Interactions between carvedilol and RCK

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

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Interactions between your drugs

Major

cloNIDine carvedilol

Applies to: RCK (clonidine / ketorolac / ropivacaine) and carvedilol

MONITOR CLOSELY: Clonidine and beta-blockers may have synergistic pharmacodynamic effects resulting in marked AV block, bradycardia, and hypotension. Conversely, cases of antagonism of hypotensive effects have been reported, the mechanism of which is unknown. In addition, potentiation of the hypertensive rebound associated with abrupt withdrawal of clonidine or both clonidine and the beta blocker may occur. Increased blood pressure, hypertensive crisis, hypertensive encephalopathy, strokes, and fatalities have been reported after clonidine withdrawal. The proposed mechanism is related to increased catecholamine release after clonidine withdrawal, and concurrent beta-blockade results in unopposed alpha-adrenergic effects of the catecholamines, resulting in vasoconstriction. Patients who discontinue clonidine while taking noncardioselective beta blockers appear to be at a higher risk of developing rebound hypertension.

MANAGEMENT: Close monitoring of blood pressure is recommended for patients receiving this combination. Patients should be advised to notify their doctor if they experience a reduced heart rate, dizziness, fainting, or headaches. Clonidine should never be discontinued abruptly, but should be tapered off over 2 to 4 days. The beta blocker should be discontinued a few days before gradually discontinuing the clonidine. It has also been suggested that replacing clonidine and the beta blocker with labetalol (an alpha and beta blocker) may prevent rebound hypertension although some symptoms from increased catecholamine levels occur, or selecting a cardioselective beta blocker (e.g. atenolol, betaxolol, bisoprolol, metoprolol) which is theoretically not expected to exacerbate the pressor response. Patients being withdrawn from clonidine should be carefully monitored for blood pressure changes, severe headache, tremors, apprehension, flushing, nausea, and vomiting.

References (5)
  1. Perks D, Fisher GC (1992) "Esmolol and clonidine: a possible interaction." Anaesthesia, 47, p. 533-4
  2. Jounela AJ, Lilja M (1984) "Interactions between beta-blockers and clonidine." Ann Clin Res, 16, p. 181-2
  3. Lilja M, Jounela AJ, Juustila H, Mattila MJ (1980) "Interaction of clonidine and beta-blockers." Acta Med Scand, 207, p. 173-6
  4. Bailey RR, Neale TJ (1976) "Rapid clonidine withdrawal with blood pressure overshoot exaggerated by beta-blockage." Br Med J, 1, p. 942-3
  5. Strauss FG, Franklin SS, Lewin AJ, Maxwell MH (1977) "Withdrawal of antihypertensive therapy. Hypertensive crisis in renovascular hypertension." JAMA, 238, p. 1734-6
Moderate

ketorolac carvedilol

Applies to: RCK (clonidine / ketorolac / ropivacaine) and carvedilol

MONITOR: Nonsteroidal anti-inflammatory drugs (NSAIDs) may attenuate the antihypertensive effect of beta-blockers. The proposed mechanism is NSAID-induced inhibition of renal prostaglandin synthesis, which results in unopposed pressor activity producing hypertension. In addition, NSAIDs can cause fluid retention, which also affects blood pressure. Indomethacin and piroxicam have been reported to have greater attenuating effects than other NSAIDs, and indomethacin effects may be significant in patients with eclampsia.

MANAGEMENT: Patients receiving a beta-blocker who require prolonged (greater than 1 week) concomitant therapy with an NSAID should have blood pressure monitored more closely following initiation, discontinuation, or change of dosage of the NSAID. The interaction is not expected to occur with low doses (e.g., low-dose aspirin) or intermittent short-term administration of NSAIDs.

References (9)
  1. Salvetti A, Pedrinelli R, Alberici P, Magagna A, Abdel-Haq B (1984) "The influence of indomethacin and sulindac on some pharmacological actions of atenolol in hypertensive patients." Br J Clin Pharmacol, 17 Suppl 1, s108-11
  2. Ylitalo P, Pitkajarvi T, Pyykonen ML, Nurmi AK, Seppala E, Vapaatalo H (1985) "Inhibition of prostaglandin synthesis by indomethacin interacts with the antihypertensive effect of atenolol." Clin Pharmacol Ther, 38, p. 443-9
  3. Radack KL, Deck CC, Bloomfield SS (1987) "Ibuprofen interferes with the efficacy of antihypertensive drugs." Ann Intern Med, 107, p. 628-35
  4. Wong DG, Spence JD, Lamki L, Freeman D, McDonald JW (1986) "Effect of non-steroidal anti-inflammatory drugs on control of hypertension by beta-blockers and diuretics." Lancet, 1, p. 997-1001
  5. Durao V, Prata MM, Goncalves LM (1977) "Modification of antihypertensive effect of beta-adrenoceptor-blocking agents by inhibition of endogenous prostaglandin synthesis." Lancet, 2, p. 1005-7
  6. Abate MA, Neely JL, Layne RD, D'Allessandri R (1991) "Interaction of indomethacin and sulindac with labetalol." Br J Clin Pharmacol, 31, p. 363-6
  7. Salvetti A, Arzilli F, Pedrinelli R, Beggi P, Motolese M (1982) "Interaction between oxprenolol and indomethacin on blood pressure in essential hypertensive patients." Eur J Clin Pharmacol, 22, p. 197-201
  8. Durao V, Prata MM, Concalves LM (1977) "Modification of antihypertensive effect of B-adrenoceptor-blocking agents by inhibition of endogenous prostaglandin synthesis." Lancet, 2, p. 1005-7
  9. Hartmann D, Stief G, Lingenfelder M, Guzelhan C, Horsch AK (1995) "Study on the possible interaction between tenoxicam and atenolol in hypertensive patients." Arzneimittelforschung, 45-1, p. 494-8

Drug and food interactions

Moderate

cloNIDine food

Applies to: RCK (clonidine / ketorolac / ropivacaine)

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. Patients should also avoid driving or operating hazardous machinery until they know how the medications affect them.

References (10)
  1. Sternbach H (1991) "Fluoxetine-associated potentiation of calcium-channel blockers." J Clin Psychopharmacol, 11, p. 390-1
  2. Shook TL, Kirshenbaum JM, Hundley RF, Shorey JM, Lamas GA (1984) "Ethanol intoxication complicating intravenous nitroglycerin therapy." Ann Intern Med, 101, p. 498-9
  3. Feder R (1991) "Bradycardia and syncope induced by fluoxetine." J Clin Psychiatry, 52, p. 139
  4. Ellison JM, Milofsky JE, Ely E (1990) "Fluoxetine-induced bradycardia and syncope in two patients." J Clin Psychiatry, 51, p. 385-6
  5. 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
  6. Cerner Multum, Inc. "Australian Product Information."
  7. Pacher P, Kecskemeti V (2004) "Cardiovascular side effects of new antidepressants and antipsychotics: new drugs, old concerns?" Curr Pharm Des, 10, p. 2463-75
  8. Andrews C, Pinner G (1998) "Postural hypotension induced by paroxetine." BMJ, 316, p. 595
  9. (2023) "Product Information. Buprenorphine (buprenorphine)." G.L. Pharma UK Ltd
  10. (2023) "Product Information. Temgesic (buprenorphine)." Reckitt Benckiser Pty Ltd
Moderate

ketorolac food

Applies to: RCK (clonidine / ketorolac / ropivacaine)

GENERALLY AVOID: The concurrent use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) and ethanol may lead to gastrointestinal (GI) blood loss. The mechanism may be due to a combined local effect as well as inhibition of prostaglandins leading to decreased integrity of the GI lining.

MANAGEMENT: Patients should be counseled on this potential interaction and advised to refrain from alcohol consumption while taking aspirin or NSAIDs.

References (1)
  1. (2002) "Product Information. Motrin (ibuprofen)." Pharmacia and Upjohn

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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