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Linezolid

Medically reviewed on Sep 10, 2018

Pronunciation

(li NE zoh lid)

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution, Intravenous:

Zyvox: 200 mg/100 mL (100 mL); 600 mg/300 mL (300 mL)

Generic: 600 mg/300 mL (300 mL)

Solution, Intravenous [preservative free]:

Generic: 600 mg/300 mL (300 mL)

Suspension Reconstituted, Oral:

Zyvox: 100 mg/5 mL (150 mL) [orange flavor]

Generic: 100 mg/5 mL (150 mL)

Tablet, Oral:

Zyvox: 600 mg

Generic: 600 mg

Brand Names: U.S.

  • Zyvox

Pharmacologic Category

  • Antibiotic, Oxazolidinone

Pharmacology

Inhibits bacterial protein synthesis by binding to bacterial 23S ribosomal RNA of the 50S subunit. This prevents the formation of a functional 70S initiation complex that is essential for the bacterial translation process. Linezolid is bacteriostatic against enterococci and staphylococci and bactericidal against most strains of streptococci.

Absorption

Rapid and extensive

Distribution

Vd:

Preterm neonates <1 week: 0.81 L/kg

Full-term neonates <1 week: 0.78 L/kg

Full-term neonates ≥1 week to ≤28 days: 0.66 L/kg

Infants >28 days to <3 months: 0.79 L/kg

Infants and Children 3 months to 11 years: 0.69 L/kg

Adolescents: 0.61 L/kg

Adults: 0.65 L/kg

Metabolism

Hepatic via oxidation of the morpholine ring, resulting in two inactive metabolites (aminoethoxyacetic acid, hydroxyethyl glycine); minimally metabolized, may be mediated by cytochrome P450

Excretion

Urine (~30% of total dose as parent drug, ~50% of total dose as metabolites); two metabolites of linezolid may accumulate in patients with severe renal impairment; feces (~9% of total dose as metabolites)

Nonrenal clearance: Adults: ~65%

Clearance:

Preterm neonates <1 week: 2 mL/minute/kg

Full-term neonates <1 week: 3.8 mL/minute/kg

Full-term neonates ≥1 week to ≤28 days: 5.1 mL/minute/kg

Infants >28 days to <3 months: 5.4 mL/minute/kg

Infants and Children 3 months to 11 years: 3.8 mL/minute/kg

Adolescents: 2.1 mL/minute/kg

Adults: 1.7 mL/minute/kg

Time to Peak

Adults: Oral: 1 to 2 hours

Half-Life Elimination

Preterm neonates <1 week: 5.6 hours

Full-term neonates <1 week: 3 hours

Full-term neonates ≥1 week to ≤28 days: 1.5 hours

Infants >28 days to <3 months: 1.8 hours

Infants and Children 3 months to 11 years: 2.9 hours

Adolescents: 4.1 hours

Adults: 4.9 hours

Protein Binding

Adults: 31%

Special Populations: Renal Function Impairment

Data are conflicting regarding the contribution of renal dysfunction to the elimination of linezolid. Several studies indicate that linezolid exposure is increased in patients with significant renal dysfunction (Cattaneo 2016; Gervasoni 2015; Ide 2018; Matsumoto 2010; Nukui 2013; Sasaki 2011; Tsuji 2017) although this may be reduced by a compensatory increase in non-renal elimination (Brier 2003; El-Assal 2014). Metabolites A and B accumulate in patients with renal insufficiency; the significance of this accumulation is not known.

Use: Labeled Indications

Enterococcal infections (vancomycin-resistant): Treatment of vancomycin-resistant (VRE) Enterococcus faecium infections, including cases with concurrent bacteremia. Note: Not a preferred agent in resistant E. faecalis infections which are usually susceptible to beta-lactams (O’Driscoll 2015).

Pneumonia:

Community-acquired: Treatment of community-acquired pneumonia (CAP) caused by Streptococcus pneumoniae, including cases with concurrent bacteremia, or Staphylococcus aureus (methicillin-susceptible isolates only). Note: Not a preferred agent for CAP; may be used as an alternate choice in multi-drug resistant S. pneumoniae and MRSA pneumonia. For methicillin-susceptible S. aureus, the use of beta-lactams is preferred (IDSA/ATS [Mandell 2007]).

Hospital-acquired or healthcare-associated: Treatment of hospital-acquired or healthcare-associated pneumonia caused by S. aureus (methicillin-susceptible and -resistant isolates), or S. pneumoniae. Note: For methicillin-susceptible S. aureus, the use of beta-lactams is preferred (IDSA/ATS [Kalil 2016]).

Skin and skin structure infections:

Complicated: Treatment of complicated skin and skin structure infections, including diabetic foot infections, without concomitant osteomyelitis, caused by S. aureus (methicillin-susceptible and -resistant isolates), Streptococcus pyogenes, or Streptococcus agalactiae.

Uncomplicated: Treatment of uncomplicated skin and skin structure infections caused by S. aureus (methicillin-susceptible isolates) or S. pyogenes.

Note: Generally reserved as alternate for skin and skin structure infections due to MRSA (IDSA [Liu 2011]; IDSA [Stevens 2014]).

Limitations of use: Linezolid has not been studied in the treatment of decubitus ulcers. Linezolid is not indicated for treatment of gram-negative infections; if a concomitant gram-negative pathogen is documented or suspected, initiate specific therapy immediately.

Off Label Uses

CNS infection due to methicillin-resistant S. aureus

Based on the Infectious Disease Society of America (IDSA) guidelines for the treatment of methicillin-resistant S. aureus (MRSA) infections in adults and children, linezolid is an effective and recommended alternative agent in the treatment of MRSA infections of the CNS, including meningitis, brain abscess, subdural empyema, spinal epidural abscess, and septic thrombosis of cavernous or dural venous sinus.

Infective endocarditis, treatment (adults)

Based on the American Heart Association (AHA) Scientific Statement for Infective Endocarditis in Adults, linezolid may be considered in the treatment of patients with infective endocarditis (native or prosthetic valve) due to Enterococcus resistant to penicillin, aminoglycosides, and vancomycin.

Intravascular catheter-associated bloodstream infection

Based on the Infectious Diseases Society of America (IDSA) guidelines for the diagnosis and management of intravascular catheter-related infection, linezolid is suggested as an alternative treatment for infection due to MRSA, methicillin-resistant coagulase negative staphylococci, and ampicillin- or vancomycin-resistant enterococcus.

Osteomyelitis (S. aureus [methicillin-resistant])

Based on the Infectious Disease Society of America (IDSA) guidelines for the treatment of methicillin-resistant S. aureus (MRSA) infections in adults and children, linezolid is effective and recommended in the treatment of MRSA bone and joint infections, including osteomyelitis.

Osteomyelitis, native vertebral

Based on the Infectious Diseases Society of America (IDSA) guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults, linezolid is an effective and recommended alternative treatment option for native vertebral osteomyelitis due to staphylococci (oxacillin-susceptible or -resistant) or Enterococcus spp. (penicillin-resistant or -sensitive).

Prosthetic joint infection

Based on the Infectious Diseases Society of America (IDSA) guidelines for the management of prosthetic joint infection, linezolid is an effective and recommended alternative agent for the treatment of prosthetic joint infection with Staphylococci (oxacillin-sensitive and oxacillin-resistant) and Enterococcus spp (penicillin-sensitive and penicillin resistant).

Septic arthritis (S. aureus [methicillin-resistant])

Based on the Infectious Disease Society of America (IDSA) guidelines for the treatment of methicillin-resistant S. aureus (MRSA) infections in adults and children, linezolid is effective and recommended in the treatment of MRSA bone and joint infections, including septic arthritis.

Tuberculosis, extensively drug-resistant:

Data from a randomized clinical trial conducted in South Korea in patients with sputum culture-positive extensively drug-resistant tuberculosis evaluating the addition of linezolid to the existing anti-tuberculosis regimen supports the use of linezolid in this condition [Lee 2012]. Additional data may be necessary to further define the role of linezolid in this condition.

Contraindications

Hypersensitivity to linezolid or any component of the formulation; concurrent use or within 2 weeks of MAO inhibitors

Canadian labeling: Additional contraindications (not in US labeling): Unless monitored for potential increases in blood pressure, linezolid should not be administered to patients with uncontrolled hypertension, pheochromocytoma, thyrotoxicosis and/or patients taking any of the following: sympathomimetic agents (eg, pseudoephedrine, phenylpropanolamine), vasopressive agents (eg, epinephrine, norepinephrine), dopaminergic agents (eg, dopamine, dobutamine). Unless carefully observed for signs and/or symptoms of serotonin syndrome, linezolid should not be administered to patients with carcinoid syndrome and/or patients taking any of the following: SSRIs, TCAs, serotonin 5-HT1 receptor agonists (triptans), meperidine or buspirone.

Dosing: Adult

Note: Linezolid is not a preferred agent in treatment of infections requiring prolonged therapy (ie, >2 weeks) due to the risk of serious hematologic and neurologic toxicity. Use of linezolid is generally reserved for treatment of infections due to drug-resistant organisms (eg, MRSA, VRE).

Enterococcal infections (vancomycin-resistant [VRE]), including concurrent bacteremia: Oral, IV: 600 mg every 12 hours

Pneumonia:

Community-acquired (CAP) due to multi-drug resistant S. pneumoniae: Oral, IV: 600 mg every 12 hours; duration dependent upon severity of illness and clinical response

CAP due to MRSA: Oral, IV: 600 mg every 12 hours for 7 to 21 days (IDSA [Liu 2011])

Hospital-acquired (HAP) or ventilator-associated (VAP) due to MRSA, MSSA, and S. pneumoniae (generally reserved for MRSA): Oral, IV: 600 mg every 12 hours for 7 days; may consider a shorter or longer duration depending on rate of clinical improvement. When used as empiric therapy, use in combination with an antipseudomonal agent (one or two antipseudomonal agents depending on patient and institution specific risk factors) (IDSA/ATS [Kalil 2016])

Skin and skin structure infections (SSI), complicated: Oral, IV: 600 mg every 12 hours for 10 to 14 days. Note: Generally reserved as an alternative for MRSA infections. For diabetic foot infections, may extend treatment duration up to 4 weeks if slow to resolve (IDSA [Lipsky 2012]).

Skin and skin structure infections (SSI), uncomplicated: Oral: 400 mg every 12 hours for 10 to 14 days. Note: Generally reserved as an alternative for MRSA infections. The dose most commonly employed clinically is 600 mg every 12 hours; a 5- to 10-day treatment course may be sufficient (IDSA [Liu 2011]; IDSA [Stevens 2014]).

CNS infection due to MRSA (off-label use): Oral, IV: 600 mg every 12 hours; duration may vary depending on type and severity of infection, as well as clinical response (IDSA [Liu 2011])

Infective endocarditis (treatment), native or prosthetic valve (off-label use): IV, Oral: Enterococcus (resistant to penicillin, aminoglycosides, and vancomycin): 600 mg every 12 hours for a minimum of 6 weeks (AHA [Baddour 2015])

Intravascular catheter-associated bloodstream infection due to MRSA, methicillin-resistant coagulase negative staphylococci, or ampicillin- or vancomycin-resistant enterococcus (off-label use): Oral, IV: 600 mg every 12 hours (IDSA [Mermel 2009])

Osteomyelitis due to MRSA (off-label use): Oral, IV: 600 mg every 12 hours for a minimum of 8 weeks (for MRSA, some experts combine with rifampin, unless patient has concurrent bacteremia; in this case, clearance of bacteremia should occur first) (Birmingham 2003; IDSA [Liu 2011]; Rao 2004).

Osteomyelitis, native vertebral (off-label use): Staphylococci (oxacillin-susceptible or –resistant) or Enterococcus spp (penicillin-susceptible or –resistant): Oral, IV: 600 mg every 12 hours for 6 weeks (IDSA [Berbari 2015])

Prosthetic joint infection (off-label use):

Enterococcus spp (penicillin-susceptible or -resistant) (alternative treatment): Oral, IV: 600 mg every 12 hours for 4 to 6 weeks (consider adding an aminoglycoside) followed by an oral antibiotic suppressive regimen (IDSA [Osmon 2013]). Note: Generally reserved for VRE.

Staphylococci (oxacillin-sensitive or -resistant) (alternative treatment): Oral, IV: 600 mg every 12 hours for 2 to 6 weeks used in combination with rifampin followed by oral antibiotic treatment and suppressive regimens (IDSA [Osmon 2013]). Note: Generally reserved for VRE.

Septic arthritis due to MRSA (off-label use): Oral, IV: 600 mg every 12 hours for 3 to 4 weeks (IDSA [Liu 2011])

Tuberculosis, extensively drug-resistant (off-label use): Oral, IV: 600 mg once daily in addition to existing regimen; continue this dose until negative sputum smears for 2 consecutive weeks or until completion of 4 months of therapy then reduce dose to 300 mg once daily and continue for at least an additional 18 months; some patients may require continued therapy with 600 mg once daily instead if there is concern for resistance due to low exposure. Patient must be monitored closely for hematologic and neurologic toxicities (Lee 2012).

Dosing: Geriatric

Refer to adult dosing.

Dosing: Pediatric

Usual dosage: Oral, IV:

Children ≤11 years: 10 mg/kg (maximum: 600 mg/dose) every 8 hours

Children ≥12 years and Adolescents: Refer to adult dosing.

Indication-specific dosing:

Enterococcal infections, vancomycin-resistant, including concurrent bacteremia: Oral, IV:

Infants and Children ≤11 years: 10 mg/kg every 8 hours for 14 to 28 days

Children ≥12 years and Adolescents: Refer to adult dosing.

Pneumonia:

Community-acquired (CAP):

Manufacturer's labeling (includes concurrent bacteremia): Oral, IV:

Infants and Children ≤11 years: 10 mg/kg/dose every 8 hours for 10 to 14 days

Children ≥12 years and Adolescents: Refer to adult dosing.

Alternate dosing:

Infants >3 months and Children ≤11 years (IDSA/PIDS 2011):

S. pneumoniae (MICs to penicillin ≤2.0 mcg/mL), mild infection or step-down therapy (alternative to amoxicillin): Oral: 10 mg/kg/dose every 8 hours

S. pneumoniae (MICs to penicillin ≥4.0 mcg/mL):

Severe infection (alternative to ceftriaxone): IV: 10 mg/kg/dose every 8 hours

Mild infection, step-down therapy (preferred): Oral: 10 mg/kg/dose every 8 hours

S. aureus (methicillin-resistant/clindamycin-susceptible):

Severe infection (alternative to vancomycin or clindamycin): IV: 10 mg/kg/dose every 8 hours

Mild infection, step-down therapy (alternative to clindamycin): Oral: 10 mg/kg/dose every 8 hours

S. aureus (methicillin- and clindamycin-resistant):

Severe infection (alternative to vancomycin): IV: 10 mg/kg/dose every 8 hours

Mild infection, step-down therapy (preferred): Oral: 10 mg/kg/dose every 8 hours

Children ≤11 years (Liu 2011): Oral, IV: S. aureus (methicillin-resistant): 10 mg/kg/dose every 8 hours for 7 to 21 days (maximum: 600 mg/dose)

Children ≥12 years and Adolescents (IDSA/PIDS 2011):

S. pneumoniae (MICs to penicillin ≤2.0 mcg/mL), mild infection or step-down therapy (alternative to amoxicillin): Oral: 10 mg/kg/dose every 12 hours

S. pneumoniae (MICs to penicillin ≥4.0 mcg/mL)

Severe infection (alternative to ceftriaxone): IV: 10 mg/kg/dose every 12 hours

Mild infection, step-down therapy (preferred): Oral: 10 mg/kg/dose every 12 hours

S. aureus (methicillin-resistant/clindamycin-susceptible):

Severe infection (alternative to vancomycin/clindamycin): IV: 10 mg/kg/dose every 12 hours

Mild infection, step-down therapy (alternative to clindamycin): Oral: 10 mg/kg/dose every 12 hours

S. aureus (methicillin- and clindamycin-resistant):

Severe infection (alternative to vancomycin): IV: 10 mg/kg/dose every 12 hours

Mild infection, step-down therapy (preferred): Oral: 10 mg/kg/dose every 12 hours

Children ≥12 years and Adolescents (Liu 2011): S. aureus (methicillin-resistant): Refer to adult dosing.

Hospital-acquired or healthcare-associated: Oral, IV:

Manufacturer's labeling:

Infants and Children ≤11 years: 10 mg/kg every 8 hours for 10 to 14 days

Children ≥12 years and Adolescents: Refer to adult dosing.

Alternate dosing (Liu 2011): S. aureus (methicillin-resistant):

Infants and Children ≤11 years: 10 mg/kg/dose every 8 hours for 7 to 21 days (maximum: 600 mg/dose)

Children ≥12 years and Adolescents: Refer to adult dosing.

Skin and skin structure infections, complicated: Oral, IV:

Infants and Children ≤11 years: 10 mg/kg every 8 hours for 10 to 14 days

Children ≥12 years and Adolescents: Refer to adult dosing.

Skin and skin structure infections, uncomplicated: Oral:

Infants and Children <5 years: 10 mg/kg every 8 hours for 10 to 14 days

Children 5 to 11 years: 10 mg/kg every 12 hours for 10 to 14 days

Children ≥12 years and Adolescents: 600 mg every 12 hours for 10 to 14 days

Brain abscess, subdural empyema, spinal epidural abscess (S. aureus [methicillin-resistant]) (off-label use) (Liu 2011): Oral, IV: Note: The manufacturer does not recommend the use of linezolid for empiric treatment of pediatric CNS infections since therapeutic linezolid concentrations are not consistently achieved or maintained in the CSF of patients with ventriculoperitoneal shunts.

Children ≤ 11 years: 10 mg/kg every 8 hours for 4 to 6 weeks (maximum: 600 mg/dose)

Children ≥12 years and Adolescents: Refer to adult dosing.

Meningitis (S. aureus [methicillin-resistant]) (off-label use) (Liu 2011): Oral, IV:

Infants and Children ≤11 years: 10 mg/kg every 8 hours for 2 weeks (maximum: 600 mg/dose)

Children ≥12 years and Adolescents: Refer to adult dosing.

Osteomyelitis (S. aureus [methicillin-resistant]) (off-label use) (Liu 2011): Oral, IV:

Infants and Children ≤11 years: 10 mg/kg every 8 hours for a minimum of 4 to 6 weeks (maximum: 600 mg/dose)

Children ≥12 years and Adolescents: Refer to adult dosing.

Septic arthritis (S. aureus [methicillin-resistant]) (off-label use) (Liu 2011): Oral, IV:

Infants and Children ≤11 years: 10 mg/kg every 8 hours for 3 to 4 weeks (maximum: 600 mg/dose)

Children ≥12 years and Adolescents: Refer to adult dosing.

Septic thrombosis of cavernous or dural venous sinus (S. aureus [methicillin-resistant]) (off-label use) (Liu 2011): Oral, IV:

Children ≤11 years: 10 mg/kg every 8 hours for 4 to 6 weeks (maximum: 600 mg/dose)

Children ≥12 years and Adolescents: Refer to adult dosing.

Dosing: Renal Impairment

Mild to severe impairment: No dosage adjustment necessary. The two primary metabolites may accumulate in patients with renal impairment but the clinical significance is unknown; use with caution.

End-stage renal disease (ESRD)on intermittent hemodialysis (IHD):

Manufacturer's labeling: Dialyzable (~30% removed during 3-hour dialysis session): No dosage adjustment necessary; administer after hemodialysis on dialysis days. The two primary metabolites may accumulate in patients with renal impairment but the clinical significance is unknown; use with caution.

Alternate dosing: If administration time is not immediately after dialysis session, may consider administration of a supplemental dose especially early in the treatment course to maintain levels above the MIC (Brier 2003). However, others have recommended no supplemental dose or dosage adjustment for patients on IHD (Heintz 2009; Trotman 2005)

Peritoneal dialysis: No supplemental dose or dosage adjustment needed (Heintz 2009; Trotman 2005)

Continuous renal replacement therapy (CVVH, CVVHD, CVVHDF): Some have suggested no supplemental dose or dosage adjustment needed (Heintz 2009; Trotman 2005). Others have postulated that achievement of MIC 2 mg/L may be suboptimal in ~30% of patients undergoing CVVHD or CVVHDF given 600 mg every 12 hours; however, no alternative dosing recommendations suggested (Roger 2016).

Dosing: Hepatic Impairment

Mild to moderate impairment (Child-Pugh class A or B): No dosage adjustment necessary.

Severe impairment (Child-Pugh class C): There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).

Dosing: Obesity

According to one study, the use of the standard dose of 600 mg every 12 hours for patients who are ≤150 kg will provide AUC values similar to that seen in non-obese adult patients; patients >150 kg were not included in the study. Use standard dosing for patients with weights ≤150 kg (Bhalodi 2013). In another study, 450 mg every 8 hours was recommended for patients with a body mass index ≥25 kg/m2 with GFRCKD-EPI ≥60 mL/minute/1.73 m2 and Staphylococcus aureus or Enterococcus spp. infections (but not coagulase-negative staphylococci). Note: 600 mg every 8 hours was associated with an unacceptable risk of toxicity (Cojutti 2018).

Reconstitution

Oral suspension: Refer to manufacturer’s product labeling for reconstitution instructions. Prior to administration mix gently by inverting bottle; do not shake.

Administration

IV: Administer intravenous infusion over 30 to 120 minutes. Do not mix or infuse with other medications. When the same intravenous line is used for sequential infusion of other medications, flush line with D5W, NS, or LR before and after infusing linezolid. The yellow color of the injection may intensify over time without affecting potency.

Oral: Administer without regard to meals.

Oral suspension: Invert gently to mix prior to administration, do not shake.

Dietary Considerations

Some products may contain sodium and/or phenylalanine. Avoid consuming large amounts of tyramine-containing foods/beverages. Some examples include aged or matured cheese, air-dried or cured meats (including sausages and salami), fava or broad bean pods, tap/draft beers, Marmite concentrate, sauerkraut, soy sauce, and other soybean condiments.

Storage

Infusion: Store at 25°C (77°F). Protect from light and freezing. Keep infusion bags in overwrap until ready for use.

Oral suspension: Store at 25°C (77°F); following reconstitution store at room temperature and use suspension within 21 days. Protect from light.

Tablet: Store at 25°C (77°F). Protect from light and moisture.

Drug Interactions

Alcohol (Ethyl): May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Avoid combination

Antiemetics (5HT3 Antagonists): May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Monitor therapy

Antipsychotic Agents: Serotonin Modulators may enhance the adverse/toxic effect of Antipsychotic Agents. Specifically, serotonin modulators may enhance dopamine blockade, possibly increasing the risk for neuroleptic malignant syndrome. Antipsychotic Agents may enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Monitor therapy

Apraclonidine: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Apraclonidine. Monoamine Oxidase Inhibitors may increase the serum concentration of Apraclonidine. Avoid combination

AtoMOXetine: Monoamine Oxidase Inhibitors may enhance the neurotoxic (central) effect of AtoMOXetine. Avoid combination

Atropine (Ophthalmic): Monoamine Oxidase Inhibitors may enhance the hypertensive effect of Atropine (Ophthalmic). Avoid combination

BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Avoid combination

BCG (Intravesical): Myelosuppressive Agents may diminish the therapeutic effect of BCG (Intravesical). Avoid combination

BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Monitor therapy

Benzhydrocodone: May enhance the serotonergic effect of Monoamine Oxidase Inhibitors. This could result in serotonin syndrome. Management: The use of benzhydrocodone is not recommended for patients taking monoamine oxidase inhibitors (MAOIs) or within 14 days of MAOI discontinuation. Consider therapy modification

Betahistine: Monoamine Oxidase Inhibitors may increase the serum concentration of Betahistine. Monitor therapy

Bezafibrate: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Bezafibrate. Avoid combination

Blood Glucose Lowering Agents: Monoamine Oxidase Inhibitors may enhance the hypoglycemic effect of Blood Glucose Lowering Agents. Monitor therapy

Brimonidine (Ophthalmic): Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Brimonidine (Ophthalmic). Monoamine Oxidase Inhibitors may increase the serum concentration of Brimonidine (Ophthalmic). Monitor therapy

Brimonidine (Topical): Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Brimonidine (Topical). Monoamine Oxidase Inhibitors may increase the serum concentration of Brimonidine (Topical). Monitor therapy

Buprenorphine: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Avoid combination

BuPROPion: Monoamine Oxidase Inhibitors may enhance the hypertensive effect of BuPROPion. Avoid combination

BusPIRone: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Specifically, blood pressure elevations been reported. Avoid combination

CarBAMazepine: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Management: Avoid concurrent use of carbamazepine during, or within 14 days of discontinuing, treatment with a monoamine oxidase inhibitor. Avoid combination

Cerebrolysin: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Monitor therapy

Chloramphenicol (Ophthalmic): May enhance the adverse/toxic effect of Myelosuppressive Agents. Monitor therapy

Chlorphenesin Carbamate: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Monitor therapy

Cholera Vaccine: Antibiotics may diminish the therapeutic effect of Cholera Vaccine. Management: Avoid cholera vaccine in patients receiving systemic antibiotics, and within 14 days following the use of oral or parenteral antibiotics. Avoid combination

CloZAPine: Myelosuppressive Agents may enhance the adverse/toxic effect of CloZAPine. Specifically, the risk for neutropenia may be increased. Monitor therapy

Codeine: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Codeine. Monitor therapy

COMT Inhibitors: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Consider therapy modification

Cyclobenzaprine: May enhance the serotonergic effect of Monoamine Oxidase Inhibitors. This could result in serotonin syndrome. Avoid combination

Cyproheptadine: Monoamine Oxidase Inhibitors may enhance the anticholinergic effect of Cyproheptadine. Cyproheptadine may diminish the serotonergic effect of Monoamine Oxidase Inhibitors. Avoid combination

Dapoxetine: May enhance the adverse/toxic effect of Serotonin Modulators. Avoid combination

Deferiprone: Myelosuppressive Agents may enhance the neutropenic effect of Deferiprone. Avoid combination

Deutetrabenazine: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Deutetrabenazine. Avoid combination

Dexmethylphenidate: Monoamine Oxidase Inhibitors may enhance the hypertensive effect of Dexmethylphenidate. Avoid combination

Dextromethorphan: Monoamine Oxidase Inhibitors may enhance the serotonergic effect of Dextromethorphan. This may cause serotonin syndrome. Avoid combination

Diethylpropion: Monoamine Oxidase Inhibitors may enhance the hypertensive effect of Diethylpropion. Avoid combination

Dihydrocodeine: May enhance the serotonergic effect of Monoamine Oxidase Inhibitors. This could result in serotonin syndrome. Monitor therapy

Diphenoxylate: May enhance the hypertensive effect of Monoamine Oxidase Inhibitors. Avoid combination

Dipyrone: May enhance the adverse/toxic effect of Myelosuppressive Agents. Specifically, the risk for agranulocytosis and pancytopenia may be increased Avoid combination

Domperidone: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Domperidone. Monoamine Oxidase Inhibitors may diminish the therapeutic effect of Domperidone. Domperidone may diminish the therapeutic effect of Monoamine Oxidase Inhibitors. Monitor therapy

DOPamine: Monoamine Oxidase Inhibitors may enhance the hypertensive effect of DOPamine. Management: Initiate dopamine at no greater than one-tenth (1/10) of the usual dose in patients who are taking (or have taken within the last 2 to 3 weeks) monoamine oxidase inhibitors. Monitor for an exaggerated hypertensive response to dopamine. Consider therapy modification

Droxidopa: Monoamine Oxidase Inhibitors may enhance the hypertensive effect of Droxidopa. Avoid combination

EPINEPHrine (Oral Inhalation): Monoamine Oxidase Inhibitors may enhance the hypertensive effect of EPINEPHrine (Oral Inhalation). Avoid combination

Epinephrine (Racemic): Monoamine Oxidase Inhibitors may enhance the hypertensive effect of Epinephrine (Racemic). Monitor therapy

FentaNYL: May enhance the serotonergic effect of Monoamine Oxidase Inhibitors. This could result in serotonin syndrome. Avoid combination

Guanethidine: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Avoid combination

Heroin: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Heroin. Avoid combination

HYDROcodone: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of HYDROcodone. Management: Consider alternatives to this combination when possible. Consider therapy modification

HYDROmorphone: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of HYDROmorphone. Avoid combination

Indoramin: Monoamine Oxidase Inhibitors may enhance the hypotensive effect of Indoramin. Avoid combination

Iobenguane Radiopharmaceutical Products: Monoamine Oxidase Inhibitors may diminish the therapeutic effect of Iobenguane Radiopharmaceutical Products. Management: Discontinue all drugs that may inhibit or interfere with catecholamine transport or uptake for at least 5 biological half-lives before iobenguane administration. Do not administer these drugs until at least 7 days after each iobenguane dose. Avoid combination

Iohexol: Agents With Seizure Threshold Lowering Potential may enhance the adverse/toxic effect of Iohexol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iohexol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic anticonvulsants. Consider therapy modification

Iomeprol: Agents With Seizure Threshold Lowering Potential may enhance the adverse/toxic effect of Iomeprol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iomeprol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic anticonvulsants. Consider therapy modification

Iopamidol: Agents With Seizure Threshold Lowering Potential may enhance the adverse/toxic effect of Iopamidol. Specifically, the risk for seizures may be increased. Management: Discontinue agents that may lower the seizure threshold 48 hours prior to intrathecal use of iopamidol. Wait at least 24 hours after the procedure to resume such agents. In nonelective procedures, consider use of prophylactic anticonvulsants. Consider therapy modification

Isometheptene: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Isometheptene. Avoid combination

Lactobacillus and Estriol: Antibiotics may diminish the therapeutic effect of Lactobacillus and Estriol. Monitor therapy

Levodopa: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Of particular concern is the development of hypertensive reactions when levodopa is used with nonselective MAOI. Management: The concomitant use of nonselective monoamine oxidase inhibitors (MAOIs) and levodopa is contraindicated. Discontinue the nonselective MAOI at least two weeks prior to initiating levodopa. Monitor patients taking a selective MAOIs and levodopa. Consider therapy modification

Levonordefrin: Monoamine Oxidase Inhibitors may enhance the hypertensive effect of Levonordefrin. Avoid combination

Lithium: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Lithium. Management: This combination should be undertaken with great caution. When combined treatment is clinically indicated, monitor closely for signs of serotonin toxicity/serotonin syndrome. Consider therapy modification

Maprotiline: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Avoid combination

Meperidine: Monoamine Oxidase Inhibitors may enhance the serotonergic effect of Meperidine. This may cause serotonin syndrome. Avoid combination

Meptazinol: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Meptazinol. Avoid combination

Mequitazine: Monoamine Oxidase Inhibitors may enhance the anticholinergic effect of Mequitazine. Avoid combination

Metaxalone: May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Monitor therapy

Methyldopa: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Methyldopa. Avoid combination

Methylene Blue: Monoamine Oxidase Inhibitors may enhance the serotonergic effect of Methylene Blue. This could result in serotonin syndrome. Avoid combination

Methylene Blue: May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Avoid combination

Methylphenidate: Monoamine Oxidase Inhibitors may enhance the hypertensive effect of Methylphenidate. Avoid combination

Metoclopramide: Serotonin Modulators may enhance the adverse/toxic effect of Metoclopramide. This may be manifest as symptoms consistent with serotonin syndrome or neuroleptic malignant syndrome. Monitor therapy

Mianserin: Monoamine Oxidase Inhibitors may enhance the neurotoxic effect of Mianserin. Avoid combination

Mirtazapine: Linezolid may enhance the serotonergic effect of Mirtazapine. This could result in serotonin syndrome. Avoid combination

Moclobemide: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Moclobemide. Avoid combination

Monoamine Oxidase Inhibitors: May enhance the adverse/toxic effect of Linezolid. Avoid combination

Morphine (Liposomal): Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Morphine (Liposomal). Avoid combination

Morphine (Systemic): Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Morphine (Systemic). Avoid combination

Nefazodone: Linezolid may enhance the serotonergic effect of Nefazodone. This could result in serotonin syndrome. Avoid combination

Nefopam: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Nefopam. Avoid combination

Opioid Analgesics: May enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Monitor therapy

OxyCODONE: May enhance the serotonergic effect of Monoamine Oxidase Inhibitors. This could result in serotonin syndrome. Management: Seek alternatives when possible. Avoid use of oxycodone/naltrexone during and within 14 days after monoamine oxidase inhibitor treatment. Non-US labeling for some oxycodone products states that such use is contraindicated. Consider therapy modification

OxyMORphone: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Avoid combination

Pheniramine: May enhance the anticholinergic effect of Monoamine Oxidase Inhibitors. Avoid combination

Pholcodine: May enhance the serotonergic effect of Monoamine Oxidase Inhibitors. This could result in serotonin syndrome. Avoid combination

Pindolol: Monoamine Oxidase Inhibitors may enhance the hypotensive effect of Pindolol. Management: Canadian labeling for pindolol states that concurrent use with a monoamine oxidase inhibitor is not recommended. Consider therapy modification

Pizotifen: Monoamine Oxidase Inhibitors may enhance the anticholinergic effect of Pizotifen. Avoid combination

Promazine: May enhance the myelosuppressive effect of Myelosuppressive Agents. Monitor therapy

Reboxetine: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Reboxetine. Avoid combination

Reserpine: Monoamine Oxidase Inhibitors may enhance the adverse/toxic effect of Reserpine. Existing MAOI therapy can result in paradoxical effects of added reserpine (e.g., excitation, hypertension). Management: Monoamine oxidase inhibitors (MAOIs) should be avoided or used with great caution in patients who are also receiving reserpine. Consider therapy modification

Selective Serotonin Reuptake Inhibitors: Linezolid may enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This could result in serotonin syndrome. Avoid combination

Serotonin 5-HT1D Receptor Agonists: Monoamine Oxidase Inhibitors may decrease the metabolism of Serotonin 5-HT1D Receptor Agonists. Management: If MAO inhibitor therapy is required, naratriptan, eletriptan or frovatriptan may be a suitable 5-HT1D agonist to employ. Exceptions: Eletriptan; Frovatriptan; Naratriptan. Avoid combination

Serotonin Modulators: Linezolid may enhance the serotonergic effect of Serotonin Modulators. This could result in serotonin syndrome. Management: Due to a risk of serotonin syndrome/serotonin toxicity, discontinue serotonin modulators 2 weeks prior to the administration of linezolid. If urgent initiation of linezolid is needed, discontinue serotonin modulators immediately and monitor closely. Exceptions: Nicergoline. Consider therapy modification

Serotonin/Norepinephrine Reuptake Inhibitors: Linezolid may enhance the serotonergic effect of Serotonin/Norepinephrine Reuptake Inhibitors. This could result in serotonin syndrome. Avoid combination

Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Consider therapy modification

SUFentanil: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Specifically, the risk for serotonin syndrome or opioid toxicities (eg, respiratory depression, coma) may be increased. Management: Sufentanil should not be used with monoamine oxidase (MAO) inhibitors (or within 14 days of stopping an MAO inhibitor) due to the potential for serotonin syndrome and/or excessive CNS depression. Avoid combination

Sympathomimetics: Linezolid may enhance the hypertensive effect of Sympathomimetics. Management: Reduce initial doses of sympathomimetic agents, and closely monitor for enhanced pressor response, in patients receiving linezolid. Specific dose adjustment recommendations are not presently available. Consider therapy modification

Tapentadol: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Specifically, the additive effects of norepinephrine may lead to adverse cardiovascular effects. Tapentadol may enhance the serotonergic effect of Monoamine Oxidase Inhibitors. This could result in serotonin syndrome. Avoid combination

Tetrabenazine: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Avoid combination

Tetrahydrozoline (Nasal): Monoamine Oxidase Inhibitors may enhance the hypertensive effect of Tetrahydrozoline (Nasal). Avoid combination

Tianeptine: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Avoid combination

TraZODone: Linezolid may enhance the serotonergic effect of TraZODone. This could result in serotonin syndrome. Avoid combination

Tricyclic Antidepressants: Linezolid may enhance the serotonergic effect of Tricyclic Antidepressants. This could result in serotonin syndrome. Avoid combination

Tryptophan: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Avoid combination

Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Vaccination with live attenuated typhoid vaccine (Ty21a) should be avoided in patients being treated with systemic antibacterial agents. Use of this vaccine should be postponed until at least 3 days after cessation of antibacterial agents. Consider therapy modification

Valbenazine: May enhance the adverse/toxic effect of Monoamine Oxidase Inhibitors. Avoid combination

Adverse Reactions

>10%:

Gastrointestinal: Diarrhea (8% to 11%)

Hematologic & oncologic: Decreased white blood cells (neonates, infants, and children: 12%; children, adolescents, and adults: ≤2%), decreased platelet count (adults: ≤10%)

1% to 10%:

Central nervous system: Headache (children, adolescents, and adults: 6% to 9%; neonates, infants, and children: <1%), dizziness (adults: 2% to 3%), vertigo (children and adolescents: 1%)

Dermatologic: Skin rash (adults: 1% to 2%), pruritus (neonates, infants, children, and adolescents: ≤1%; nonapplication site)

Endocrine & metabolic: Increased amylase (≤2%), increased lactate dehydrogenase (adults: ≤2%)

Gastrointestinal: Vomiting (3% to 9%), nausea (2% to 7%), increased serum lipase (adults: 3% to 4%; children and adolescents: <1%), loose stools (neonates, infants, children, and adolescents: 2%), abdominal pain (≤2%), oral candidiasis (adults: ≤2%), dysgeusia (adults: 1% to 2%), tongue discoloration (≤1%)

Genitourinary: Vulvovaginal candidiasis (adults: 1% to 2%)

Hematologic & oncologic: Anemia (neonates, infants, and children: 6%; adults ≤2%), decreased neutrophils (neonates, infants, and children: 6%; children, adolescents, and adults: ≤1%), thrombocytopenia (neonates, infants, and children: 5%), eosinophilia (neonates, infants, children, and adolescents: ≤2%)

Hepatic: Increased serum ALT (2% to 10%), increased serum bilirubin (neonates, infants, and children: 6%; adults: <1%), increased serum AST (adults: 2% to 5%), increased serum alkaline phosphatase (adults: ≤4%), abnormal hepatic function tests (adults: ≤2%)

Infection: Fungal infection (adults: ≤2%)

Renal: Increased blood urea nitrogen (adults: ≤2%), increased serum creatinine (≤2%)

<1%, postmarketing, and/or case reports: Anaphylaxis, angioedema, blurred vision, bone marrow depression, bullous skin disease, Clostridium difficile associated diarrhea, dental discoloration, hypoglycemia, lactic acidosis, optic neuropathy, pancytopenia, peripheral neuropathy, seizure, serotonin syndrome (with concurrent use of other serotonergic agents), severe dermatological reaction, sideroblastic anemia, Stevens-Johnson syndrome, toxic epidermal necrolysis, vision loss

Warnings/Precautions

Concerns related to adverse effects:

• Lactic acidosis: Has been reported with use. Patients who develop recurrent nausea and vomiting, unexplained acidosis, or low bicarbonate levels need immediate evaluation.

• Myelosuppression: Has been reported and may be dependent on duration of therapy (generally >2 weeks of treatment); use with caution in patients with preexisting myelosuppression, in patients receiving other drugs which may cause bone marrow suppression, or in chronic infection (previous or concurrent antibiotic therapy). Weekly CBC monitoring is recommended; consider discontinuation in patients developing myelosuppression (or in whom myelosuppression worsens during treatment). Thrombocytopenia is the most frequently observed blood dyscrasia.

• Peripheral and optic neuropathy (with vision loss): Has been reported in adults and children and may occur primarily with extended courses of therapy >28 days; any symptoms of visual change or impairment warrant immediate ophthalmic evaluation and possible discontinuation of therapy.

• Serotonin syndrome: Symptoms of agitation, confusion, hallucinations, hyper-reflexia, myoclonus, shivering, and tachycardia may occur with concomitant proserotonergic drugs, agents which reduce linezolid's metabolism, or in patients with carcinoid syndrome. Avoid use in such patients unless clinically appropriate and under close monitoring for signs/symptoms of serotonin syndrome or neuroleptic malignant syndrome-like reactions.

• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including C. difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.

Disease-related concerns:

• Carcinoid syndrome: Use with caution and closely monitor for serotonin syndrome in patients with carcinoid syndrome; linezolid has not been studied in patients with this condition. Do not use in the absence of close monitoring.

• Diabetes mellitus: Hypoglycemic episodes have been reported; use with caution and closely monitor glucose in diabetic patients. Dose reductions/discontinuation of concurrent hypoglycemic agents or discontinuation of linezolid may be required.

• Hypertension: Use with caution and closely monitor blood pressure in patients with uncontrolled hypertension; linezolid has not been studied in patients with this condition. Do not use in the absence of close monitoring.

• Hyperthyroidism: Use with caution and closely monitor blood pressure in patients with untreated hyperthyroidism; linezolid has not been studied in patients with this condition. Do not use in the absence of close monitoring.

• Pheochromocytoma: Use with caution and closely monitor blood pressure in patients with pheochromocytoma; linezolid has not been studied in patients with this condition. Do not use in the absence of close monitoring.

• Seizure disorder: Seizures have been reported; use with caution in patients with a history of seizures.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Pediatric: The manufacturer does not recommend the use of linezolid for empiric treatment of pediatric CNS infections since therapeutic linezolid concentrations are not consistently achieved or maintained in the CSF of patients with ventriculoperitoneal shunts. However, limited data in the form of case reports in pediatric and adult patients suggest that linezolid may be useful in treating gram-positive CNS infections that have failed to respond to other treatment options describing successful treatment of documented VRE and Staphylococcus aureus CNS and shunt infections in the literature (Cook 2005; da Silva 2007; Milstone 2007; Shaikh 2001; Villani 2002).

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC, 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol derivative with caution in neonates. See manufacturer’s labeling.

• Phenylalanine: Some products may contain phenylalanine.

Other warnings/precautions:

• Appropriate use: Unnecessary use may lead to the development of resistance to linezolid; consider alternatives before initiating outpatient treatment.

• Catheter-related bloodstream infections (CRBSI): Linezolid should not be used in the empiric treatment of CRBSI, but may be appropriate for targeted therapy (Mermel 2009).

Monitoring Parameters

Weekly CBC, particularly in patients at increased risk of bleeding, with pre-existing myelosuppression, on concomitant medications that cause bone marrow suppression, in those who require >2 weeks of therapy, or in those with chronic infection who have received previous or concomitant antibiotic therapy; peripheral sensory and visual function with extended therapy (≥3 months) or in patients with new onset neuropathic or visual symptoms, regardless of therapy length; in patients with renal impairment, monitor for hematopoietic (eg, anemia, leukopenia, thrombocytopenia) and neuropathic (eg, peripheral neuropathy) adverse events when administering for extended periods. Periodic serum bicarbonate with extended therapy. Consider monitoring lactic acid in patients with renal dysfunction (Mori 2018).

Linezolid has been found to have significant interpatient variability (Cattaneo 2016; Pea 2010; Pea 2017) and limited data suggest that monitoring linezolid trough concentrations may be used to optimize dosing, especially in patients with renal dysfunction (Cattaneo 2016; Gervasoni 2015; Pea 2017) and/or concern for thrombocytopenia (Matsumoto 2010; Nukui 2013; Tsuji 2017).

Pregnancy Risk Factor

C

Pregnancy Considerations

Adverse effects were observed in some animal reproduction studies at doses that were also maternally toxic. Information related to linezolid use during pregnancy is limited.

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience nausea, vomiting, or diarrhea. Have patient report immediately to prescriber signs of infection, signs of lactic acidosis (fast breathing, tachycardia, abnormal heartbeat, vomiting, drowsiness, shortness of breath, loss of strength and energy, severe dizziness, feeling cold, or muscle pain or cramps), signs of low blood sugar (dizziness, headache, fatigue, feeling weak, shaking, tachycardia, confusion, increased hunger, or sweating), signs of serotonin syndrome (dizziness, severe headache, agitation, hallucinations, tachycardia, abnormal heartbeat, flushing, tremors, sweating a lot, change in balance, severe nausea, or severe diarrhea), vision changes, severe headache, dizziness, passing out, seizures, vision changes, burning or numbness feeling, severe loss of strength and energy, or signs of Clostridium difficile (C. diff)-associated diarrhea (abdominal pain or cramps, severe diarrhea or watery stools, or bloody stools) (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.

Further information

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