Drug Interactions between iobenguane I 123 and milnacipran

GENERALLY AVOID: Coadministration with drugs that block norepinephrine uptake or deplete norepinephrine stores may decrease iobenguane I-123 uptake in neuroendocrine tumors and lead to false-negative imaging results. Since iobenguane I-123 is subject to the same uptake and accumulation pathways as norepinephrine, drugs that alter norepinephrine disposition in adrenergic nerve terminals and presynaptic storage vesicles will likewise affect iobenguane. These drugs include antihypertensive agents that deplete norepinephrine stores or inhibit reuptake (e.g., guanethidine, reserpine, labetalol); antidepressants that inhibit norepinephrine transporter function (e.g., tricyclic antidepressants, selective serotonin reuptake inhibitors); sympathomimetic amines (e.g., phenylephrine, phenylpropanolamine, pseudoephedrine, ephedrine); central nervous stimulants (e.g., amphetamines); phenothiazines; and cocaine. Clinical studies have not determined which specific drugs may cause false-negative imaging results and whether all drugs in a specific pharmacologic class have the same potential to produce negative imaging results. Increasing the dose of iobenguane I-123 will not overcome any potential effect of these drugs.

MANAGEMENT: When medically feasible, any drug that blocks norepinephrine uptake or deplete norepinephrine stores should be discontinued for at least five biological half-lives before iobenguane I-123 administration. Patients should be monitored for the occurrence of clinically significant withdrawal symptoms, especially patients with elevated levels of circulating catecholamines and their metabolites.