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Drug Interactions between chlorpheniramine / ephedrine / guaifenesin and phenylephrine / promethazine

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

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Interactions between your drugs

Moderate

ePHEDrine phenylephrine

Applies to: chlorpheniramine / ephedrine / guaifenesin and phenylephrine / promethazine

MONITOR: Coadministration of two or more sympathomimetic agents may increase the risk of adverse effects such as nervousness, irritability, and increased heart rate. Central nervous system (CNS) stimulants, particularly amphetamines, can potentiate the adrenergic response to vasopressors and other sympathomimetic agents. Additive increases in blood pressure and heart rate may occur due to enhanced peripheral sympathetic activity.

MANAGEMENT: Caution is advised if two or more sympathomimetic agents are coadministered. Pulse and blood pressure should be closely monitored.

References

  1. Rosenblatt JE, Lake CR, van Kammen DP, Ziegler MG, Bunney WE Jr (1979) "Interactions of amphetamine, pimozide, and lithium on plasma norepineophrine and dopamine-beta-hydroxylase in schizophrenic patients." Psychiatry Res, 1, p. 45-52
  2. Cavanaugh JH, Griffith JD, Oates JA (1970) "Effect of amphetamine on the pressor response to tyramine: formation of p-hydroxynorephedrine from amphetamine in man." Clin Pharmacol Ther, 11, p. 656
  3. (2001) "Product Information. Adderall (amphetamine-dextroamphetamine)." Shire Richwood Pharmaceutical Company Inc
  4. (2001) "Product Information. Tenuate (diethylpropion)." Aventis Pharmaceuticals
  5. (2001) "Product Information. Sanorex (mazindol)." Novartis Pharmaceuticals
  6. (2001) "Product Information. Focalin (dexmethylphenidate)." Mikart Inc
  7. (2002) "Product Information. Strattera (atomoxetine)." Lilly, Eli and Company
View all 7 references

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Moderate

chlorpheniramine promethazine

Applies to: chlorpheniramine / ephedrine / guaifenesin and phenylephrine / promethazine

MONITOR: Agents with anticholinergic properties (e.g., sedating antihistamines; antispasmodics; neuroleptics; phenothiazines; skeletal muscle relaxants; tricyclic antidepressants; disopyramide) may have additive effects when used in combination. Excessive parasympatholytic effects may result in paralytic ileus, hyperthermia, heat stroke, and the anticholinergic intoxication syndrome. Peripheral symptoms of intoxication commonly include mydriasis, blurred vision, flushed face, fever, dry skin and mucous membranes, tachycardia, urinary retention, and constipation. Central symptoms may include memory loss, disorientation, incoherence, hallucinations, psychosis, delirium, hyperactivity, twitching or jerking movements, stereotypy, and seizures. Central nervous system-depressant effects may also be additively or synergistically increased when these agents are combined, especially in elderly or debilitated patients. Use of neuroleptics in combination with other neuroleptics or anticholinergic agents may increase the risk of tardive dyskinesia. In addition, some neuroleptics and tricyclic antidepressants may cause prolongation of the QT interval and theoretically, concurrent use of two or more drugs that can cause QT interval prolongation may result in additive effects and increased risk of ventricular arrhythmias including torsade de pointes and sudden death.

MANAGEMENT: Caution is advised when agents with anticholinergic properties are combined, particularly in the elderly and those with underlying organic brain disease, who tend to be more sensitive to the central anticholinergic effects of these drugs and in whom toxicity symptoms may be easily overlooked. Patients should be advised to notify their physician promptly if they experience potential symptoms of anticholinergic intoxication such as abdominal pain, fever, heat intolerance, blurred vision, confusion, and/or hallucinations. Ambulatory patients should be counseled to avoid activities requiring mental alertness until they know how these agents affect them. A reduction in anticholinergic dosages may be necessary if excessive adverse effects develop.

References

  1. Stadnyk AN, Glezos JD (1983) "Drug-induced heat stroke." Can Med Assoc J, 128, p. 957-9
  2. Zelman S, Guillan R (1970) "Heat stroke in phenothiazine-treated patients: a report of three fatalities." Am J Psychiatry, 126, p. 1787-90
  3. Mann SC, Boger WP (1978) "Psychotropic drugs, summer heat and humidity, and hyperplexia: a danger restated." Am J Psychiatry, 135, p. 1097-100
  4. Warnes H, Lehmann HE, Ban TA (1967) "Adynamic ileus during psychoactive medication: a report of three fatal and five severe cases." Can Med Assoc J, 96, p. 1112-3
  5. Gershon S, Neubauer H, Sundland DM (1965) "Interaction between some anticholinergic agents and phenothiazines." Clin Pharmacol Ther, 6, p. 749-56
  6. Sarnquist F, Larson CP Jr (1973) "Drug-induced heat stroke." Anesthesiology, 39, p. 348-50
  7. Johnson AL, Hollister LE, Berger PA (1981) "The anticholinergic intoxication syndrome: diagnosis and treatment." J Clin Psychiatry, 42, p. 313-7
  8. Lee BS (1986) "Possibility of hyperpyrexia with antipsychotic and anticholinergic drugs." J Clin Psychiatry, 47, p. 571
  9. Forester D (1978) "Fatal drug-induced heat stroke." JACEP, 7, p. 243-4
  10. Moreau A, Jones BD, Banno V (1986) "Chronic central anticholinergic toxicity in manic depressive illness mimicking dementia." Can J Psychiatry, 31, p. 339-41
  11. Hvizdos AJ, Bennett JA, Wells BG, Rappaport KB, Mendel SA (1983) "Anticholinergic psychosis in a patient receiving usual doses of haloperidol." Clin Pharm, 2, p. 174-8
  12. Cohen MA, Alfonso CA, Mosquera M (1994) "Development of urinary retention during treatment with clozapine and meclizine [published erratum appears in Am J Psychiatry 1994 Jun;151(6):952]." Am J Psychiatry, 151, p. 619-20
  13. (2001) "Product Information. Cogentin (benztropine)." Merck & Co., Inc
  14. Kulik AV, Wilbur R (1982) "Delirium and stereotypy from anticholinergic antiparkinson drugs." Prog Neuropsychopharmacol Biol Psychiatry, 6, p. 75-82
  15. (2001) "Product Information. Artane (trihexyphenidyl)." Lederle Laboratories
View all 15 references

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Moderate

ePHEDrine promethazine

Applies to: chlorpheniramine / ephedrine / guaifenesin and phenylephrine / promethazine

GENERALLY AVOID: Phenothiazines may antagonize the pharmacologic effects of amphetamine, amphetamine derivatives, and other centrally-acting sympathomimetic agents (i.e., CNS stimulants). Conversely, these agents may diminish the neuroleptic efficacy of phenothiazines. The exact mechanism of interaction is unknown but may involve opposing effects on dopaminergic activity. Several clinical studies have demonstrated the reduction or lack of effect of amphetamines on weight loss in obese psychiatric patients treated with chlorpromazine and other neuroleptic agents. In one of these studies, dextroamphetamine also had no effect on sleep patterns. As for the reverse interaction, it is uncertain whether CNS stimulants actually antagonize the neuroleptic effect of phenothiazines, since CNS stimulants alone have been reported to cause or aggravate preexisting psychotic symptoms. Finally, it is conceivable that, because of their sympathomimetic effects, CNS stimulants may also potentiate the arrhythmogenicity of phenothiazines. A case of fatal ventricular arrhythmia was reported in a patient treated chronically with thioridazine who ingested a single capsule containing phenylpropanolamine 50 mg and chlorpheniramine 4 mg. However, a causal relationship was not established.

MANAGEMENT: Amphetamine, amphetamine derivatives, and other CNS stimulants should generally not be used, particularly for weight reduction, in patients treated with phenothiazines.

References

  1. Reid AA (1964) "Pharmacological antagonism between chlorpromazine and phenmetrazine in mental hospital patients." Med J Aust, 1, p. 187-8
  2. Sletten IW, Ognjanov V, Menendez S, Sundland D, El-Toumi A (1967) "Weight reduction with chlorphentermine and phenmetrazine in obese psychiatric patients during chlorpromazine therapy." Curr Ther Res Clin Exp, 9, p. 570-5
  3. Chouinard G, Ghadirian AM, Jones BD (1978) "Death attributed to ventricular arrhythmia induced by thioridazine in combination with a single Contac*C capsule." Can Med Assoc J, 119, p. 729-31
  4. Casey JF, Hollister LE, Klett CJ, Lasky JJ, Caffey EM (1961) "Combined drug therapy of chronic schizophrenics." Am J Psychiatry, 177, p. 997
  5. Modell W, Hussar AE (1965) "Failure of dextroamphetamine sulfate to incluence eating and sleeping patterns in obese schizophrenic patients." JAMA, 193, p. 275-8
  6. Angrist B, Lee HK, Gershon S (1974) "The antagonism of amphetamine-induced symptomatology by a neuroleptic." Am J Psychiatry, 131, p. 817-9
  7. Cornelius JR, Soloff PH, Reynolds CF, 3d (1984) "Paranoia, homicidal behavior, and seizures associated with phenylpropanolamine." Am J Psychiatry, 141, p. 120-1
  8. Achor MB, Extein I (1981) "Diet aids, mania, and affective illness" Am J Psychiatry, 138, p. 392
  9. Schaffer CB, Pauli MW (1980) "Psychotic reaction caused by proprietary oral diet agents." Am J Psychiatry, 137, p. 1256-7
  10. Grieger TA, Clayton AH, Goyer PF (1990) "Affective disorder following use of phenylpropanolamine" Am J Psychiatry, 147, p. 367-8
  11. Dietz AJ, Jr (1981) "Amphetamine-like reactions to phenylpropanolamine." JAMA, 245, p. 601-2
  12. Norvenius G, Widerlov E, Lonnerholm G (1979) "Phenylpropanolamine and mental disturbances" Lancet, 2, p. 1367-8
  13. Mueller SM (1983) "Neurologic complications of phenylpropanolamine use." Neurology, 33, p. 650-2
  14. Lake CR, Tenglin R, Chernow B, Holloway HC (1983) "Psychomotor stimulant-induced mania in a genetically predisposed patient: a review of the literature and report of a case." J Clin Psychopharmacol, 3, p. 97-100
  15. Lake CR (1991) "Manic psychosis after coffee and phenylpropanolamine." Biol Psychiatry, 30, p. 401-4
  16. Lambert MT (1987) "Paranoid psychoses after abuse of proprietary cold remedies." Br J Psychiatry, 151:, p. 548-50
  17. Wharton BK (1970) "Nasal decongestants and paranoid psychosis." Br J Psychiatry, 117, p. 439-40
  18. Dewsnap P, Libby G (1992) "A case of affective psychosis after routine use of proprietary cold remedy containing phenylpropanolamine" Hum Exp Toxicol, 11, p. 295-6
  19. Finton CK, Barton M, Chernow B (1982) "Possible adverse effects of phenylpropanolamine (diet pills) on sympathetic nervous system function--caveat emptor!" Mil Med, 147, p. 1072
  20. Stroe AE, Hall J, Amin F (1995) "Psychotic episode related to phenylpropanolamine and amantadine in a healthy female." Gen Hosp Psychiatry, 17, p. 457-8
  21. Marshall RD, Douglas CJ (1994) "Phenylpropanolamine-induced psychosis: potential predisposing factors." Gen Hosp Psychiatry, 16, p. 358-60
  22. (2001) "Product Information. Fastin (phentermine)." SmithKline Beecham
  23. (2001) "Product Information. Cylert (pemoline)." Abbott Pharmaceutical
  24. (2001) "Product Information. Ritalin (methylphenidate)." Novartis Pharmaceuticals
  25. (2001) "Product Information. Desoxyn (methamphetamine)." Abbott Pharmaceutical
  26. (2001) "Product Information. Dexedrine (dextroamphetamine)." SmithKline Beecham
  27. (2001) "Product Information. Adderall (amphetamine-dextroamphetamine)." Shire Richwood Pharmaceutical Company Inc
  28. (2001) "Product Information. Didrex (benzphetamine)." Pharmacia and Upjohn
  29. (2001) "Product Information. Prelu-2 (phendimetrazine)." Boehringer-Ingelheim
  30. (2001) "Product Information. Tenuate (diethylpropion)." Aventis Pharmaceuticals
  31. (2001) "Product Information. Sanorex (mazindol)." Novartis Pharmaceuticals
  32. Markowitz JS, Patrick KS (2001) "Pharmacokinetic and pharmacodynamic drug interactions in the treatment of attention-deficit hyperactivity disorder." Clin Pharmacokinet, 40, p. 753-72
  33. (2001) "Product Information. Focalin (dexmethylphenidate)." Mikart Inc
  34. (2007) "Product Information. Vyvanse (lisdexamfetamine)." Shire US Inc
View all 34 references

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Drug and food interactions

Moderate

chlorpheniramine food

Applies to: chlorpheniramine / ephedrine / guaifenesin

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

MANAGEMENT: Patients receiving CNS-active agents should be warned of this interaction and advised to avoid or limit consumption of alcohol. Ambulatory patients should be counseled to avoid hazardous activities requiring complete 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. (2012) "Product Information. Fycompa (perampanel)." Eisai Inc
  4. (2015) "Product Information. Rexulti (brexpiprazole)." Otsuka American Pharmaceuticals Inc
View all 4 references

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Moderate

promethazine food

Applies to: phenylephrine / promethazine

GENERALLY AVOID: Concurrent use of ethanol and phenothiazines may result in additive CNS depression and psychomotor impairment. Also, ethanol may precipitate dystonic reactions in patients who are taking phenothiazines. The two drugs probably act on different sites in the brain, although the exact mechanism of the interaction is not known.

MANAGEMENT: Patients should be advised to avoid alcohol during phenothiazine therapy.

References

  1. Lutz EG (1976) "Neuroleptic-induced akathisia and dystonia triggered by alcohol." JAMA, 236, p. 2422-3
  2. Freed E (1981) "Alcohol-triggered-neuroleptic-induced tremor, rigidity and dystonia." Med J Aust, 2, p. 44-5

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Moderate

ePHEDrine food

Applies to: chlorpheniramine / ephedrine / guaifenesin

MONITOR: Coadministration of two or more sympathomimetic agents may increase the risk of adverse effects such as nervousness, irritability, and increased heart rate. Central nervous system (CNS) stimulants, particularly amphetamines, can potentiate the adrenergic response to vasopressors and other sympathomimetic agents. Additive increases in blood pressure and heart rate may occur due to enhanced peripheral sympathetic activity.

MANAGEMENT: Caution is advised if two or more sympathomimetic agents are coadministered. Pulse and blood pressure should be closely monitored.

References

  1. Rosenblatt JE, Lake CR, van Kammen DP, Ziegler MG, Bunney WE Jr (1979) "Interactions of amphetamine, pimozide, and lithium on plasma norepineophrine and dopamine-beta-hydroxylase in schizophrenic patients." Psychiatry Res, 1, p. 45-52
  2. Cavanaugh JH, Griffith JD, Oates JA (1970) "Effect of amphetamine on the pressor response to tyramine: formation of p-hydroxynorephedrine from amphetamine in man." Clin Pharmacol Ther, 11, p. 656
  3. (2001) "Product Information. Adderall (amphetamine-dextroamphetamine)." Shire Richwood Pharmaceutical Company Inc
  4. (2001) "Product Information. Tenuate (diethylpropion)." Aventis Pharmaceuticals
  5. (2001) "Product Information. Sanorex (mazindol)." Novartis Pharmaceuticals
  6. (2001) "Product Information. Focalin (dexmethylphenidate)." Mikart Inc
  7. (2002) "Product Information. Strattera (atomoxetine)." Lilly, Eli and Company
View all 7 references

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Moderate

phenylephrine food

Applies to: phenylephrine / promethazine

MONITOR: Coadministration of two or more sympathomimetic agents may increase the risk of adverse effects such as nervousness, irritability, and increased heart rate. Central nervous system (CNS) stimulants, particularly amphetamines, can potentiate the adrenergic response to vasopressors and other sympathomimetic agents. Additive increases in blood pressure and heart rate may occur due to enhanced peripheral sympathetic activity.

MANAGEMENT: Caution is advised if two or more sympathomimetic agents are coadministered. Pulse and blood pressure should be closely monitored.

References

  1. Rosenblatt JE, Lake CR, van Kammen DP, Ziegler MG, Bunney WE Jr (1979) "Interactions of amphetamine, pimozide, and lithium on plasma norepineophrine and dopamine-beta-hydroxylase in schizophrenic patients." Psychiatry Res, 1, p. 45-52
  2. Cavanaugh JH, Griffith JD, Oates JA (1970) "Effect of amphetamine on the pressor response to tyramine: formation of p-hydroxynorephedrine from amphetamine in man." Clin Pharmacol Ther, 11, p. 656
  3. (2001) "Product Information. Adderall (amphetamine-dextroamphetamine)." Shire Richwood Pharmaceutical Company Inc
  4. (2001) "Product Information. Tenuate (diethylpropion)." Aventis Pharmaceuticals
  5. (2001) "Product Information. Sanorex (mazindol)." Novartis Pharmaceuticals
  6. (2001) "Product Information. Focalin (dexmethylphenidate)." Mikart Inc
  7. (2002) "Product Information. Strattera (atomoxetine)." Lilly, Eli and Company
View all 7 references

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Therapeutic duplication warnings

Therapeutic duplication is the use of more than one medicine from the same drug category or therapeutic class to treat the same condition. This can be intentional in cases where drugs with similar actions are used together for demonstrated therapeutic benefit. It can also be unintentional in cases where a patient has been treated by more than one doctor, or had prescriptions filled at more than one pharmacy, and can have potentially adverse consequences.

Duplication

Antihistamines

Therapeutic duplication

The recommended maximum number of medicines in the 'antihistamines' category to be taken concurrently is usually one. Your list includes two medicines belonging to the 'antihistamines' category:

  • chlorpheniramine/ephedrine/guaifenesin
  • phenylephrine/promethazine

Note: In certain circumstances, the benefits of taking this combination of drugs may outweigh any risks. Always consult your healthcare provider before making changes to your medications or dosage.

Duplication

Decongestants

Therapeutic duplication

The recommended maximum number of medicines in the 'decongestants' category to be taken concurrently is usually one. Your list includes two medicines belonging to the 'decongestants' category:

  • chlorpheniramine/ephedrine/guaifenesin
  • phenylephrine/promethazine

Note: In certain circumstances, the benefits of taking this combination of drugs may outweigh any risks. Always consult your healthcare provider before making changes to your medications or dosage.

Duplication

Sympathomimetics

Therapeutic duplication

The recommended maximum number of medicines in the 'sympathomimetics' category to be taken concurrently is usually one. Your list includes two medicines belonging to the 'sympathomimetics' category:

  • chlorpheniramine/ephedrine/guaifenesin
  • phenylephrine/promethazine

Note: In certain circumstances, the benefits of taking this combination of drugs may outweigh any risks. Always consult your healthcare provider before making changes to your medications or dosage.

Duplication

Sympathomimetic amines

Therapeutic duplication

The recommended maximum number of medicines in the 'sympathomimetic amines' category to be taken concurrently is usually one. Your list includes two medicines belonging to the 'sympathomimetic amines' category:

  • chlorpheniramine/ephedrine/guaifenesin
  • phenylephrine/promethazine

Note: In certain circumstances, the benefits of taking this combination of drugs may outweigh any risks. Always consult your healthcare provider before making changes to your medications or dosage.

See also

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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

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

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