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Drug Interactions between fentanyl / ropivacaine and Pavulon

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

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Interactions between your drugs

Moderate

fentaNYL pancuronium

Applies to: fentanyl / ropivacaine and Pavulon (pancuronium)

MONITOR: Alfentanil or fentanyl, when combined with neuromuscular blocking agents during surgical procedures, may adversely affect cardiovascular function. Tachycardia, bradycardia, and/or hypotension may result.

MANAGEMENT: The patient should be monitored closely for altered hemodynamics.

References

  1. Taylor B, MacEwen P (1989) "Asystole after alfentanil-succinylcholine." Can J Anaesth, 36, p. 255-6
  2. (2001) "Product Information. Alfenta (alfentanil)." Janssen Pharmaceuticals
  3. Reid C, Crosby E, Reid D (1991) "Sinus arrest following administration of alfentanil." Can J Anaesth, 38, p. 540-1

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Moderate

pancuronium ROPivacaine

Applies to: Pavulon (pancuronium) and fentanyl / ropivacaine

MONITOR: Neuromuscular-blocking effects may be potentiated when neuromuscular blocking agents are coadministered with local anesthetics, however, the mechanism is not completely understood. In one study of 10 healthy volunteers evaluating the use of regional anesthesia with intravenous prilocaine with (n=5) or without mivacurium (n=5), prolonged weakness was observed in subjects who received both prilocaine and mivacurium, compared to the control group. Another study of patients undergoing orthognathic surgery (n=16) evaluated the degree of neuromuscular blockade using the train of four (TOF) prior to induction and during maintenance anesthesia with propofol, fentanyl and rocuronium, with or without an oral mucosal injection of lidocaine 1% with epinephrine 10 mcg/mL (LE). The TOF ratio began to decrease 2 minutes after the injection of LE, reached a minimum value of approximately 3% twelve minutes after the injection, and then began to recover, indicating an increase in neuromuscular blockade when LE was administered with rocuronium compared to the control group. In another study of healthy patients (n=30), the effect of epidural bupivacaine on the duration, intensity, and reversal of atracurium-induced neuromuscular muscular blockade was evaluated. In the epidural bupivacaine group (n=15), the duration of neuromuscular blockade, time until first response to TOF, and reversal time were all significantly prolonged when compared to the control group. Clinical data for all neuromuscular blocking agents and local anesthetics are lacking.

MANAGEMENT: Monitoring for prolonged and/or enhanced neuromuscular blockade is advised if local anesthetics are coadministered with neuromuscular-blocking agents. Individual product labeling for the neuromuscular blocking agent should be consulted for specific recommendations and guidance.

References

  1. Pouttu J, Tuominen MK, Rosenberg PH (1988) "Cardiovascular responses caused by the combination of lidocaine and vecuronium in the induction of general anaesthesia." Acta Anaesthesiol Scand, 32, p. 549-52
  2. Fukuda S, Wakuta K, Ishikawa T, Oshita S, Sakabe T, Takeshita H (1987) "Lidocaine modifies the effect of succinylcholine on muscle oxygen consumption in dogs." Anesth Analg, 66, p. 325-8
  3. Matsuo S, Rao DBS, Chaudry I, Foldes FF (1978) "Interaction of muscle relaxants and local anesthetics at the neuromuscular junction." Anesth Analg, 57, p. 580-7
  4. Bruckner J, Thomas KC, Bikhazi GB, Foldes FF (1980) "Neuromuscular drug interactions of clinical importance." Anesth Analg, 59, p. 678-82
  5. Harrah MD, Way WL, Katzung BG (1970) "The interaction of d-tubocurarine with antiarrhythmic drugs." Anesthesiology, 33, p. 406-10
  6. Miller RD, Way WL (1971) "Inhibition of succinylcholine-induced increased intragastric pressure by nondepolarizing muscle relaxants and lidocaine." Anesthesiology, 34, p. 185-8
  7. (2019) "Product Information. Rocuronium Bromide (rocuronium)." Hospira Inc
  8. (2022) "Product Information. Anectine (succinylcholine)." Sandoz Inc
  9. (2024) "Product Information. Lidocaine Hydrochloride (lidocaine)." Hospira Inc.
  10. (2015) "Product Information. Lidocaine Hydrochloride (lidocaine)." Hospira Healthcare Corporation
  11. (2022) "Product Information. Lidocaine Hydrochloride (lidocaine)." Hameln Pharma Ltd
  12. (2022) "Product Information. Xylocaine HCl (lidocaine)." Aspen Pharmacare Australia Pty Ltd
  13. Ninomiya A, Terakawa Y, Matsuura N, Ichinohe T, Kaneko Y (2024) Oral mucosal injection of a local anesthetic solution containing epinephrine enhances muscle relaxant effects of rocuronium https://pubmed.ncbi.nlm.nih.gov/22428970/
  14. Torrance JM, lewer bm, Galletly DC (2024) Low-dose mivacurium supplementation of prilocaine i.v. regional anaesthesia https://pubmed.ncbi.nlm.nih.gov/9068344/
  15. toft p, nielsen hk, severinsen i, Helbo-Hanson HS (2024) Effect of epidurally administered bupivacaine on atracurium-induced neuromuscular blockade https://pubmed.ncbi.nlm.nih.gov/2275325/
  16. (2023) "Product Information. Cisatracurium Besylate (cisatracurium)." Hikma Pharmaceuticals USA Inc.
View all 16 references

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Drug and food interactions

Major

fentaNYL food

Applies to: fentanyl / ropivacaine

GENERALLY AVOID: Alcohol may potentiate the central nervous system (CNS) depressant effects of opioid analgesics including fentanyl. Concomitant use may result in additive CNS depression and impairment of judgment, thinking, and psychomotor skills. In more severe cases, hypotension, respiratory depression, profound sedation, coma, or even death may occur.

GENERALLY AVOID: Consumption of grapefruit juice during treatment with oral transmucosal formulations of fentanyl may result in increased plasma concentrations of fentanyl, which is primarily metabolized by CYP450 3A4 isoenzyme in the liver and intestine. Certain compounds present in grapefruit are known to inhibit CYP450 3A4 and may increase the bioavailability of swallowed fentanyl (reportedly up to 75% of a dose) and/or decrease its systemic clearance. The clinical significance is unknown. In 12 healthy volunteers, consumption of 250 mL regular-strength grapefruit juice the night before and 100 mL double-strength grapefruit juice one hour before administration of oral transmucosal fentanyl citrate (600 or 800 mcg lozenge) did not significantly affect fentanyl pharmacokinetics, overall extent of fentanyl-induced miosis (miosis AUC), or subjective self-assessment of various clinical effects compared to control. However, pharmacokinetic alterations associated with interactions involving grapefruit juice are often subject to a high degree of interpatient variability. The possibility of significant interaction in some patients should be considered.

MANAGEMENT: Patients should not consume alcoholic beverages or use drug products that contain alcohol during treatment with fentanyl. Any history of alcohol or illicit drug use should be considered when prescribing fentanyl, and therapy initiated at a lower dosage if necessary. Patients should be closely monitored for signs and symptoms of sedation, respiratory depression, and hypotension. Due to a high degree of interpatient variability with respect to grapefruit juice interactions, patients treated with fentanyl should preferably avoid the consumption of grapefruit and grapefruit juice. In addition, patients receiving transdermal formulations of fentanyl should be cautioned that drug interactions and drug effects may be observed for a prolonged period beyond removal of the patch, as significant amounts of fentanyl are absorbed from the skin for 17 hours or more after the patch is removed.

References

  1. "Product Information. Duragesic Transdermal System (fentanyl)." Janssen Pharmaceutica, Titusville, NJ.
  2. (2001) "Product Information. Actiq (fentanyl)." Abbott Pharmaceutical
  3. Kharasch ED, Whittington D, Hoffer C (2004) "Influence of Hepatic and Intestinal Cytochrome P4503A Activity on the Acute Disposition and Effects of Oral Transmucosal Fentanyl Citrate." Anesthesiology, 101, p. 729-737
  4. Tateishi T, Krivoruk Y, Ueng YF, Wood AJ, Guengerich FP, Wood M (1996) "Identification of human cytochrome P-450 3A4 as the enzyme responsible for fentanyl and sufentanil N-dealkylation." Anesth Analg, 82, p. 167-72
  5. Labroo RB, Paine MF, Thummel KE, Kharasch ED (1997) "Fentanyl metabolism by human hepatic and intestinal cytochrome P450 3A4: implicaitons for interindividual variability in disposition, efficacy, and drug interactions." Drug Metab Dispos, 25, p. 1072-80
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.

Further information

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