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Kow CS, Sunter W, Hasan SS. Management of Comedication in Hospitalized COVID-19 Patients With Atrial Fibrillation. Hosp Pharm 2021; 56:629-632. [PMID: 34732912 DOI: 10.1177/0018578720947354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Chia Siang Kow
- International Medical University, Kuala Lumpur, Malaysia
| | - Wendy Sunter
- Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK
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Kow CS, Thiruchelvam K, Hasan SS. Pharmacotherapeutic considerations for the management of cardiovascular diseases among hospitalized COVID-19 patients. Expert Rev Cardiovasc Ther 2020; 18:475-485. [PMID: 32700573 DOI: 10.1080/14779072.2020.1797492] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Cardiovascular diseases (CVDs) are among the most frequently identified comorbidities in hospitalized patients with COVID-19. Patients with CV comorbidities are typically prescribed with long-term medications. We reviewed the management of co-medications prescribed for CVDs among hospitalized COVID-19 patients. AREAS COVERED There is no specific contraindication or caution related to COVID-19 on the use of antihypertensives unless patients develop severe hypotension from septic shock where all antihypertensives should be discontinued or severe hyperkalemia in which continuation of renin-angiotensin system inhibitors is not desired. The continuation of antiplatelet or statin is not desired when severe thrombocytopenia or severe transminitis develop, respectively. Patients with atrial fibrillation receiving oral anticoagulants, particularly those who are critically ill, should be considered for substitution to parenteral anticoagulants. EXPERT OPINION An individualized approach to medication management among hospitalized COVID-19 patients with concurrent CVDs would seem prudent with attention paid to changes in clinical conditions and medications intended for COVID-19. The decision to modify prescribed long-term CV medications should be entailed by close follow-up to check if a revision on the decision is needed, with resumption of any long-term CV medication before discharge if it is discontinued during hospitalization for COVID-19, to ensure continuity of care.
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Affiliation(s)
- Chia Siang Kow
- School of Postgraduate Studies, International Medical University , Kuala Lumpur, Malaysia
| | | | - Syed Shahzad Hasan
- School of Biomedical Sciences & Pharmacy, University of Newcastle , Callaghan, Australia.,Department of Pharmacy, University of Huddersfield , Huddersfield, UK
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Serious bleeding events due to warfarin and antibiotic co-prescription in a cohort of veterans. Am J Med 2014; 127:657-663.e2. [PMID: 24657899 PMCID: PMC4116816 DOI: 10.1016/j.amjmed.2014.01.044] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 01/28/2014] [Accepted: 01/29/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND Antibiotics may interact with warfarin, increasing the risk for significant bleeding events. METHODS This is a retrospective cohort study of veterans who were prescribed warfarin for 30 days without interruption through the US Department of Veterans Affairs between October 1, 2002 and September 1, 2008. Antibiotics considered to be high risk for interaction with warfarin include: trimethoprim/sulfamethoxazole (TMP/SMX), ciprofloxacin, levofloxacin, metronidazole, fluconazole, azithromycin, and clarithromycin. Low-risk antibiotics include clindamycin and cephalexin. Risk of bleeding event within 30 days of antibiotic exposure was measured using Cox proportional hazards regression, adjusted for demographic characteristics, comorbid conditions, and receipt of other medications interacting with warfarin. RESULTS A total of 22,272 patients met inclusion criteria, with 14,078 and 8194 receiving high- and low-risk antibiotics, respectively. There were 93 and 36 bleeding events in the high- and low-risk groups, respectively. Receipt of a high-risk antibiotic (hazard ratio [HR] 1.48; 95% confidence interval [CI], 1.00-2.19) and azithromycin (HR 1.93; 95% CI, 1.13-3.30) were associated with increased risk of bleeding as a primary diagnosis. TMP/SMX (HR 2.09; 95% CI, 1.45-3.02), ciprofloxacin (HR 1.87; 95% CI, 1.42-2.50), levofloxacin (HR 1.77; 95% CI, 1.22-2.50), azithromycin (HR 1.64; 95% CI, 1.16-2.33), and clarithromycin (HR 2.40; 95% CI, 1.16-4.94) were associated with serious bleeding as a primary or secondary diagnosis. International normalized ratio (INR) alterations were common; 9.7% of patients prescribed fluconazole had INR value >6. Patients who had INR performed within 3-14 days of co-prescription were at a decreased risk of serious bleeding (HR 0.61; 95% CI, 0.42-0.88). CONCLUSIONS Warfarin users who are prescribed high-risk antibiotics are at higher risk for serious bleeding events. Early INR evaluation may mitigate this risk.
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Effect of Azithromycin on Anticoagulation-Related Outcomes in Geriatric Patients Receiving Warfarin. Clin Ther 2013; 35:425-30. [DOI: 10.1016/j.clinthera.2013.02.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 02/13/2013] [Accepted: 02/14/2013] [Indexed: 11/22/2022]
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Nutescu E, Chuatrisorn I, Hellenbart E. Drug and dietary interactions of warfarin and novel oral anticoagulants: an update. J Thromb Thrombolysis 2011; 31:326-43. [PMID: 21359645 DOI: 10.1007/s11239-011-0561-1] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Clinicians and patients around the world have been intrigued by the concept of developing an oral anticoagulant with a broad therapeutic window and few drug and dietary interactions that can be administered at fixed doses with no or minimal monitoring. The recently approved oral direct thrombin inhibitor dabigatran, along with the emerging oral anti-factor Xa inhibitors, rivaroxaban, apixaban, and edoxaban, have been developed to address many of the shortcomings of warfarin therapy. As warfarin is associated with extensive food and drug interactions, there is also a need to consider such interactions with the new oral anticoagulants. While to date few drug and dietary interactions have been reported with the new oral anticoagulants, it is still early in their development and clinical use cycle. Pharmacokinetic and pharmacodynamic profiles will have to be closely accounted for when determining the likelihood of a potential drug interaction prior to therapy initiation. As the list of drugs and supplements that interact with warfarin is continuously expanding, and the knowledge on drug interactions with the novel oral anticoagulants is still in its infancy, clinicians need to be vigilant when initiating any of these agents or when any changes in the patient's medication profile occur and perform a close screening for potential drug and dietary interactions. The objective of this paper is to give an update on drug and dietary interactions with warfarin and the novel oral anticoagulants, dabigatran, rivaroxaban, apixaban, and edoxaban.
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Affiliation(s)
- Edith Nutescu
- Department of Pharmacy Practice and Center for Pharmacoeconomic Research, University of Illinois at Chicago, College of Pharmacy, 833 S. Wood St. MC 886, Rm 164, Chicago, IL 60612, USA.
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Barranco VP. Update on clinically significant drug interactions in dermatology. J Am Acad Dermatol 2006; 54:676-84. [PMID: 16546592 DOI: 10.1016/j.jaad.2006.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2005] [Revised: 12/01/2005] [Accepted: 01/03/2006] [Indexed: 11/15/2022]
Abstract
Although there are thousands of drug interactions (DIs) listed in computers and manuals, only about 10% are clinically significant. Equally disturbing is these systems fail to detect up to one third of all dangerous DIs. This update on clinically significant DIs is current through September 2005 and discusses systemic drugs important to dermatologists. In addition, 4 aspects of DIs are discussed that are helpful in replacing rote memory with a step-by-step, logical approach based on scientific evidence.
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Affiliation(s)
- Vincent P Barranco
- Department of Dermatology, Schusterman Health Sciences Center, The University of Oklahoma, College of Medicine-Tulsa, Tulsa, Oklahoma, USA.
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Abstract
Macrolide antibiotics have been licensed since the 1950s and have an important role in the treatment of a diverse range of infectious diseases. Macrolide antibiotics have antibacterial activity against gram-positive bacteria, some gram-negative bacteria and intracellular pathogens. The spectrum of antibacterial activity combined with excellent intracellular and tissue penetration has led to the extensive use of this class of drugs in respiratory disease. Macrolide antibiotics also have demonstrated anti-inflammatory properties in various in vitro and in vivo model systems. Novel antimicrobial and anti-inflammatory properties of macrolide may result in clinical benefits, particularly in conditions where the infectious agent is inherently resistant to macrolides. Three randomized control trials have demonstrated improved lung function in patients treated with the macrolide antibiotic, azithromycin. Azithromycin was generally well tolerated and resulted in reduction in the inflammatory response which may be due to an immunomodulatory role. Short term studies (three to six months) have not demonstrated the development of increased bacterial resistance or the emergence of new pathogens following azithromycin.
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Affiliation(s)
- S C Bell
- Adult Cystic Fibrosis Unit, Department of Thoracic Medicine, The Prince Charles Hospital, Brisbane, Australia.
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Abstract
A 57-year-old Caucasian woman came to the clinic with symptoms of an upper respiratory tract infection. She was treated with a 5-day course of oral azithromycin 500 mg on day 1, then 250 mg/day for 4 days. During this period, the patient decreased her cigarette smoking from 1 pack/day to 1 pack every 3 days. No additional confounding variables were present. Two days after the completion of therapy, her international normalized ratio (INR) was 8.32. Six case reports documented in the literature have suggested an azithromycin-warfarin interaction with a resultant increase in INR. Many confounding variables existed in each of these cases, such as hepatic dysfunction, poor appetite, and concomitant drugs that resulted in an increased anticoagulant response. We report a case that involved only one potential confounding variable. Continued documentation of azithromycin-warfarin interactions is valuable considering no mention of this drug interaction exists in most tertiary references and in the package insert for azithromycin, the demonstration that no drug interaction occurred in a retrospective review of 52 cases, and the widespread use of azithromycin in the community. Clinicians should be mindful when prescribing azithromycin in combination with warfarin, and INR values should be monitored.
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Affiliation(s)
- Sarah P Shrader
- Department of Pharmacy and Clinical Sciences, College of Pharmacy, Medical University of South Carolina, Charleston, South Carolina 29425, USA
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McCall KL, Anderson HG, Jones AD. Determination of the lack of a drug interaction between azithromycin and warfarin. Pharmacotherapy 2004; 24:188-94. [PMID: 14998219 DOI: 10.1592/phco.24.2.188.33148] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To determine the effect on the international normalized ratio (INR) of adding azithromycin to patients receiving stable dosages of warfarin. DESIGN Retrospective chart review. SETTING Outpatient clinic. PATIENTS Ambulatory patients receiving warfarin and azithromycin concurrently who had a documented therapeutic INR value before the start of azithromycin therapy (pre-INR) and a documented INR value within 30 days after the start of azithromycin therapy (post-INR). MEASUREMENTS AND MAIN RESULTS Patients given felodipine during long-term warfarin therapy formed a comparative control group. Patient demographics were similar in both treatment groups. Mean age of the azithromycin group (17 patients) was 59 +/- 13 years and of the control group (20 patients) 65 +/- 12 years. All 17 patients in the azithromycin group and 16 of the controls were women. Mean change from pre-INR to post-INR in the azithromycin and control groups, respectively, was 0.14 +/- 0.64 (pre-INR 2.46, post-INR 2.61) and 0.19 +/- 0.54 (pre-INR 2.46, post-INR 2.66) (p = 0.74). A post hoc power analysis based on a pooled standard deviation of 0.60 revealed that the study had 68% power to detect a 0.5 change in the INR value. CONCLUSION No interaction between azithromycin and warfarin was observed in ambulatory patients with therapeutic baseline INR values.
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Affiliation(s)
- Kenneth L McCall
- School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, Texas 79106, USA.
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Rao KB, Pallaki M, Tolbert SR, Hornick TR. Enhanced hypoprothrombinemia with warfarin due to azithromycin. Ann Pharmacother 2004; 38:982-5. [PMID: 15084685 DOI: 10.1345/aph.1d489] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To report a case of probable azithromycin-warfarin drug interaction with enhanced hypoprothrombinemic effect of warfarin. CASE SUMMARY An 83-year-old African American man stabilized on warfarin therapy (10 mg on Wednesdays, 7.5 mg on other days) developed a prolonged prothrombin time one day after starting azithromycin 500 mg. The elevated prothrombin time normalized 3 days after azithromycin was discontinued. After the initial increase in the international normalized ratio, the absence of any significant confounding factors affecting the anticoagulant effect of warfarin in our patient and the numerous reports of such interactions indicate that an interaction between azithromycin and warfarin may have been responsible for the elevated prothrombin time seen in this patient. An objective causality assessment revealed that the adverse event was probably related to the combination of these drugs. DISCUSSION Azithromycin, unlike erythromycin and clarithromycin, is not known to inhibit the cytochrome P450 enzyme system and is presumed to be the macrolide of choice in patients already on warfarin. However, previously reported cases of azithromycin-warfarin interactions support the possibility that azithromycin does interact with warfarin, although the exact mechanism is not understood. CONCLUSIONS Azithromycin may interact with warfarin and enhance its hypoprothrombinemic effects. This effect may be delayed for 4-8 days after a course of azithromycin has been completed. Periodic monitoring of the prothrombin time is recommended when using azithromycin in patients taking warfarin.
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Affiliation(s)
- Krishnamoorthy B Rao
- Case Western Reserve University and University Hospitals of Cleveland, Cleveland, OH 44106, USA
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Abstract
The macrolides are generally well tolerated when used for the treatment of acute infections. Even when given long term for prophylaxis, there are few discontinuations due to side-effects. There are isolated reports of QT(c) prolongation in patients treated with erythromycin and other 14-membered-ring macrolides. Since the 14-membered-ring macrolides are metabolized by P450 isoenzymes, there is the potential for interaction with other therapeutic agents also metabolized in this way. Pharmacokinetic studies have demonstrated interactions between either erythromycin or clarithromycin and cyclosporin, cisapride, pimozide, disopyramide, astemizole, carbamazepine, midazolam, digoxin, hydroxymethylglutaryl-coenzyme A reductase inhibitors (i.e. 'statins') and warfarin. In patients receiving such concurrent therapy, azithromycin may be superior to erythromycin and clarithromycin.
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Affiliation(s)
- E Rubinstein
- Infectious Diseases Unit, Chaim Sheba Medical Center, Tel Aviv University School of Medicine, IL-52621 Tel-Hashomer, Israel.
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Westphal JF. Macrolide - induced clinically relevant drug interactions with cytochrome P-450A (CYP) 3A4: an update focused on clarithromycin, azithromycin and dirithromycin. Br J Clin Pharmacol 2000; 50:285-95. [PMID: 11012550 PMCID: PMC2015000 DOI: 10.1046/j.1365-2125.2000.00261.x] [Citation(s) in RCA: 150] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2000] [Accepted: 07/05/2000] [Indexed: 11/20/2022] Open
Affiliation(s)
- J F Westphal
- Unit of Geriatric Medicine, Drug and Therapeutics Committee, Etablissement Public de Santé Alsace Nord, BP 83, 67170 Brumath Strasbourg, France
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Beckey NP, Parra D, Colon A. Retrospective evaluation of a potential interaction between azithromycine and warfarin in patients stabilized on warfarin. Pharmacotherapy 2000; 20:1055-9. [PMID: 10999497 DOI: 10.1592/phco.20.13.1055.35026] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To investigate a potential interaction between azithromycin and warfarin. DESIGN Retrospective case-control study. SETTING Veterans Affairs medical center. PATIENTS Fifty-two patients stable on anticoagulation therapy. INTERVENTION Patients who received a prescription for azithromycin and warfarin at any time since the hospital was opened, June 1, 1995, to July 22, 1999, were identified through a computerized report generated from the pharmacy prescription package. MEASUREMENTS AND MAIN RESULTS Patients having a stable international normalized ratio (INR; defined as a therapeutic INR +/- 0.2) for at least two consecutive visits before receiving an azithromycin prescription were reviewed. Changes in INR from before and after addition of azithromycin were compared with changes in a control group. Controls were identified from a computer-generated report of patients who received a prescription for terazosin and warfarin at any time since the hospital was opened to July 22, 1999 (terazosin was chosen as it has no known interaction with warfarin). These patients also had a stable INR for at least two consecutive visits before receiving the terazosin prescription. In patients with INRs on record within 14 days after starting azithromycin or terazosin (9 patients/group), the average change in INR was 0.18 +/- 0.48 in the azithromycin group and 0.07 +/- 0.49 in the terazosin group (p=0.60). For patients with an INR on record within 30 days after starting azithromycin or terazosin (26 patients/group), the average change in INR was 0.25 +/- 0.67 in the azithromycin group and 0.05 +/- 0.55 in the terazosin group (p=0.18). CONCLUSION An interaction between azithromycin and warfarin was not observed in this retrospective review of patients with a stable INR receiving the combination.
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Affiliation(s)
- N P Beckey
- Department of Veterans Affairs Medical Center, West Palm Beach, Florida 33410, USA
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Abstract
OBJECTIVE To describe the current drug interaction profiles for the commonly used macrolides in the US and Europe, and to comment on the clinical impact of these interactions. DATA SOURCES A MEDLINE search (1975-1998) was performed to identify all pertinent studies, review articles, and case reports. When appropriate information was not available in the literature, data were obtained from the product manufacturers. STUDY SELECTION All available data were reviewed to provide an unbiased account of possible drug interactions. DATA EXTRACTION Data for some of the interactions were not available from the literature, but were available from abstracts or company-supplied materials. Although the data were not always explicit, the best attempt was made to deliver pertinent information that clinical practitioners would need to formulate practice opinions. When more in-depth information was supplied in the form of a review or study report, a thorough explanation of pertinent methodology was supplied. DATA SYNTHESIS Several clinically significant drug interactions have been identified since the approval of erythromycin. These interactions usually were related to the inhibition of the cytochrome P450 enzyme systems, which are responsible for the metabolism of many drugs. The decreased metabolism by the macrolides has in some instances resulted in potentially severe adverse events. The development and marketing of newer macrolides are hoped to improve the drug interaction profile associated with this class. However, this has produced variable success. Some of the newer macrolides demonstrated an interaction profile similar to that of erythromycin; others have improved profiles. The most success in avoiding drug interactions related to the inhibition of cytochrome P450 has been through the development of the azalide subclass, of which azithromycin is the first and only to be marketed. Azithromycin has not been demonstrated to inhibit the cytochrome P450 system in studies using a human liver microsome model, and to date has produced none of the classic drug interactions characteristic of the macrolides. CONCLUSIONS Most of the available data regarding macrolide drug interactions are from studies in healthy volunteers and case reports. These data suggest that clarithromycin appears to have an interaction profile similar to that of erythromycin. Given this similarity, it is important to consider the interaction profile of clarithromycin when using erythromycin. This is especially necessary as funds for further studies of a medication available in generic form (e.g., erythromycin) are limited. Azithromycin has produced few clinically significant interactions with any agent cleared through the cytochrome P450 enzyme system. Although the available data are promising, the final test should come from studies conducted in patients who are taking potentially interacting compounds on a chronic basis.
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Affiliation(s)
- M P Pai
- Clinical Pharmacology Research Center, Bassett Healthcare, Cooperstown, NY 13326, USA
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Abstract
Azithromycin is considered unlikely to interact with warfarin. Unlike other macrolide antibiotics, it is not hepatically metabolized and did not produce an interaction with warfarin in a single-dose study. A 71-year-old woman with a prosthetic heart valve, stabilized with warfarin, had international normalized ratios (INRs) maintained between 2.5 and 3.5. Six days after she received a prescription for a 5-day course of azithromycin, her INR was 15.16. Phytonadione 10 mg was administered subcutaneously, and warfarin was held for 3 days until her INR fell to 2.10. She then was restabilized with warfarin. Until more information is known about the safety of warfarin and azithromycin, caution is advised when the agents are given together. Close monitoring of INR is recommended, and warfarin dosage adjustment may be necessary.
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Affiliation(s)
- D R Foster
- College of Pharmacy and Allied Health Professions, Wayne State University, Detroit, Michigan, USA
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Gooderham MJ, Bolli P, Fernandez PG. Concomitant digoxin toxicity and warfarin interaction in a patient receiving clarithromycin. Ann Pharmacother 1999; 33:796-9. [PMID: 10466907 DOI: 10.1345/aph.18330] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE To report a case of a clarithromycin-associated warfarin interaction and digoxin toxicity in a patient. CASE SUMMARY A 72-year-old white woman with chronic atrial fibrillation receiving long-standing therapy with digoxin 0.25 mg/d and warfarin 22.5 mg/wk was prescribed clarithromycin 500 mg three times daily for eradication of Helicobacter pylori. The patient presented to the emergency department with gastrointestinal symptoms, weakness, dizziness, and visual changes 12 days after initiation of clarithromycin. Laboratory results revealed a serum digoxin concentration of 4.6 ng/mL (normal 1.0-2.6) and an international normalized ratio of 7.3 (2.0-3.0). Digoxin, warfarin, and clarithromycin were discontinued and the patient was admitted to the hospital for treatment to resolve the symptoms and to return laboratory values to a safe range. Reduced dosages of digoxin (0.125 mg/d) and warfarin (17.5 mg/wk) were restarted on day 7 of hospitalization. The patient was discharged on day 11 in good condition. DISCUSSION Several reports of clarithromycin-induced drug interactions with digoxin and with warfarin have been published. Previously, case reports of macrolide-associated interactions mainly involved erythromycin, but more recently have implicated clarithromycin. The interaction between clarithromycin and warfarin is thought to occur from an inhibition of the cytochrome P450 drug metabolizing system. Clarithromycin is thought to cause digoxin toxicity by an alteration of the digoxin-metabolizing gut flora, thereby causing an increase in the digoxin concentration in susceptible individuals. Drug interactions can occur by different mechanisms in the same patient. CONCLUSIONS Potential drug interactions can occur between commonly prescribed medications. It is important to monitor patients for symptoms and alterations in laboratory values to prevent not only serious complications, but also unnecessary hospitalizations.
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Zaremba CD. Comment: could acetaminophen have played a role in a possible azithromycin-warfarin interaction? Ann Pharmacother 1998; 32:844-5. [PMID: 9681108 DOI: 10.1177/106002809803200701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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