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Drug Interactions between Cymbalta and enoxaparin

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

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Interactions between your drugs

Moderate

enoxaparin DULoxetine

Applies to: enoxaparin and Cymbalta (duloxetine)

MONITOR: Serotonin reuptake inhibitors may potentiate the risk of bleeding in patients receiving heparin therapy. The exact mechanism is unknown but may involve a pharmacodynamic interaction, as serotonin reuptake inhibitors have been reported to interfere with platelet function. A case of abdominal bleeding was reported in an elderly patient who had been treated with fluoxetine for over a year and tinzaparin for 5 days prior to hospital admission. A potential drug interaction as well as accumulation of tinzaparin secondary to impaired renal function were suspected as the cause of bleeding.

MANAGEMENT: Caution is recommended if a serotonin reuptake inhibitor is administered with heparin therapy, especially in the elderly and patients with renal impairment. Patients should be advised to promptly report any signs of bleeding to their physician, including pain, swelling, headache, dizziness, weakness, prolonged bleeding from cuts, increased menstrual flow, vaginal bleeding, nosebleeds, bleeding of gums from brushing, unusual bleeding or bruising, red or brown urine, or red or black stools.

References (27)
  1. Aranth J, Lindberg C (1992) "Bleeding, a side effect of fluoxetine." Am J Psychiatry, 149, p. 412
  2. Yaryura-Tobias JA, Kirschen H, Ninan P, Mosberg HJ (1991) "Fluoxetine and bleeding in obsessive-compulsive disorder." Am J Psychiatry, 148, p. 949
  3. Humphries JE, Wheby MS, VandenBerg SR (1990) "Fluoxetine and the bleeding time." Arch Pathol Lab Med, 114, p. 727-8
  4. Alderman CP, Moritz CK, Ben-Tovim DI (1992) "Abnormal platelet aggregation associated with fluoxetine therapy." Ann Pharmacother, 26, p. 1517-9
  5. (2001) "Product Information. Zoloft (sertraline)." Roerig Division
  6. (2001) "Product Information. Prozac (fluoxetine)." Dista Products Company
  7. (2001) "Product Information. Effexor (venlafaxine)." Wyeth-Ayerst Laboratories
  8. (2001) "Product Information. Paxil (paroxetine)." GlaxoSmithKline
  9. Messiha FS (1993) "Fluoxetine - adverse effects and drug-drug interactions." J Toxicol Clin Toxicol, 31, p. 603-30
  10. Ottervanger JP, Stricker BH, Huls J, Weeda JN (1994) "Bleeding attributed to the intake of paroxetine." Am J Psychiatry, 151, p. 781-2
  11. (2001) "Product Information. Luvox (fluvoxamine)." Solvay Pharmaceuticals Inc
  12. Krivy J, Wiener J (1995) "Sertraline and platelet counts in idiopathic thrombocytopenia purpura." Lancet, 345, p. 132
  13. Skop BP, Brown TM (1996) "Potential vascular and bleeding complications of treatment with selective serotonin reuptake inhibitors." Psychosomatics, 37, p. 12-6
  14. Pai VB, Kelly MW (1996) "Bruising associated with the use of fluoxetine." Ann Pharmacother, 30, p. 786-8
  15. Alderman CP, Seshadri P, Ben-Tovim DI (1996) "Effects of serotonin reuptake inhibitors on hemostasis." Ann Pharmacother, 30, p. 1232-4
  16. Leung M, Shore R (1996) "Fluvoxamine-associated bleeding." Can J Psychiatry, 41, p. 604-5
  17. (2001) "Product Information. Celexa (citalopram)." Forest Pharmaceuticals
  18. Settle EC (1998) "Antidepressant drugs: disturbing and potentially dangerous adverse effects." J Clin Psychiatry, 59 Suppl 16, p. 25-30
  19. Hergovich N, Aigner M, Eichler HG, Entlicher J, Drucker C, Jilma B (2000) "Paroxetine decreases platelet serotonin storage and platelet function in human beings." Clin Pharmacol Ther, 68, p. 435-42
  20. Layton D, Clark DWJ, Pearce GL, Shakir SAW (2001) "Is there an association between selective serotonin reuptake inhibitors and risk of abnormal bleeding? Results from a cohort study based on prescription event monitoring in England." Eur J Clin Pharmacol, 57, p. 167-76
  21. (2002) "Product Information. Lexapro (escitalopram)." Forest Pharmaceuticals
  22. de Maistre E, Allart C, Lecompte T, Bollaert PE (2002) "Severe bleeding associated with use of low molecular weight heparin and selective serotonin reuptake inhibitors." Am J Med, 113, p. 530-2
  23. (2004) "Product Information. Cymbalta (duloxetine)." Lilly, Eli and Company
  24. (2008) "Product Information. Pristiq (desvenlafaxine)." Wyeth Laboratories
  25. (2009) "Product Information. Savella (milnacipran)." Forest Pharmaceuticals
  26. (2013) "Product Information. Fetzima (levomilnacipran)." Forest Pharmaceuticals
  27. (2013) "Product Information. Brintellix (vortioxetine)." Takeda Pharmaceuticals America

Drug and food interactions

Moderate

DULoxetine food

Applies to: Cymbalta (duloxetine)

GENERALLY AVOID: Use of duloxetine in conjunction with chronic alcohol consumption may potentiate the risk of liver injury. Duloxetine alone can increase serum transaminase levels. In clinical trials, 0.3% of patients discontinued duloxetine due to liver transaminase elevations. The median time to detection was about two months. Three duloxetine-treated patients had liver injury as manifested by transaminase and bilirubin elevations, with evidence of obstruction. Substantial intercurrent ethanol use was present in each of these cases, which may have contributed to the abnormalities observed. Duloxetine does not appear to enhance the central nervous system effects of alcohol. When duloxetine and ethanol were administered several hours apart so that peak concentrations of each would coincide, duloxetine did not increase the impairment of mental and motor skills caused by alcohol.

MANAGEMENT: Due to the risk of liver injury, patients prescribed duloxetine should be counseled to avoid excessive use of alcohol. Duloxetine should generally not be prescribed to patients with substantial alcohol use.

References (1)
  1. (2004) "Product Information. Cymbalta (duloxetine)." Lilly, Eli and Company

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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