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CYP 450 Substrate Inducers Inhibitors

3A4 (2C9, 2D6, P glycoproteins, etc.)

PS PROCS G PACMAN (aggressive angry guy)

Phenytoin, Smoking, Phenobarbital Grapefruit, Protease Inhibitors

Rifampin (Rifabutin, Rifapentine) Azoles, Cyclosporine & cimetidine

Oxcarbazepine, Carbamazepine Macrolides Clarithro, Erythro &

S.t John Wort Telithrom

Amiodarone & Dronedarone

Non DHPCCB Diltiazem & Verapamil

Decrease the dose 30-50 % of the following drugs when administering with Amiodarone

Digoxin, Warfarin, Statins, Procainamide and Quinidine

Digoxin levels can be increased due to Decrease Renal function, Hypokalemia and CYP-Inhibitors

Caution with other drugs that decrease Heart Rate (< 60 BPM) ‘Non ABCO’ – Non-DHP CCBs,

Amiodarone, Beta-Blockers, Clonidine and Opioids/Organophosphates

Contraindicated with

NSAIDs, Aspirin, APAP and other Antiplatelets Increased bleeding risk and Increase INR

Antibiotics (Cipro, Clarithro, Metronidazole, Sulfa/Trimeth (Bactrim) Increased effect of Warfarin

Herbal drugs Ginkgo biloba, Feverfew, Ginger, Garlic Increased bleeding risk

– If given together they can increase the Risk of Severe Rash

– Risk of Serotonin Syndrome / Hypertensive crisis (Fever, Diarrhea,

Agitation, Sweating and Tremors) - Contraindicated with

Talha Shafique Drugs SSRI, SNRI, TCA, Ephedrine & Pseudoephedrine, Tramadol, Meperidine, Dextromethorphan,

Bupropion, Lithium, Cyclosporine, Muscle relaxants, Methylene Blue, Linezolid, Levodopa, Triptans

Herbal supplements St. john’s wort

Monoamines Epinephrine, NE, Dopamine, Serotonin, Tyramine

– Both metabolize with 2D6 Enzymes

Patients without 2D6 or 2D6-Inhibitors will have increase concentrations and lead to Respiratory

depression

– Prodrug of Morphine which is converted by 2D6

Patients with increased 2D6 enzymes can lead to Increase Morphine and Vice-versa

– All metabolized by 3A4 (Avoid 3A4

Inhibitors)

Antacids, Bile-acid Resins, Sucralfate and Minerals (Mg, Ca, Al, Zinc, Iron) and Multivitamins

– Increase doses can lead to Muscle toxicity and Rhabdomyolysis

Statin with increased 3A4 activity ‘SAL’ – Simvastatin, Atorvastatin and Lovastatin

Avoid with CYP-Inhibitors

– All azoles are Inhibitors

Ketoconazole & Itraconazole Both have pH-dependent absorption

NSAIDS including COX-inhibitors, all increase BP (APAP is safer)

Triptans, Stimulants, Amphetamines, TKIs, ESAs, COX-2, Antidepressants, Dihydro-Ergotamine

– RAAS (ACEi, ARBs, Aldosterone) and K-sparing Diuretics

– Increased lithium levels when used with NSAID or Diuretics

Decreased Effectiveness with CYP-Inducers and Antibiotics

Mostly are CYP-3A4 substrate (Caution with CYP inhibitors and inducers)

With Alpha-blockers Additive vasodilation = Reduction in BP

With Nitrates Both increases cGMP = Reduction in BP

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– Increase the concentration of others

Increase Bleeding risk with Anticoagulants and can increase risk of QT-Prolongation

Muscle weakness/Rhabdomyolysis & Leg pain if used with Statins (Atorvastatin, Lovastatin)

Eating too much vit. K rich foods can interact with Blood thinning drugs, especially Warfarin and can

decrease the ability of these drugs to prevent clotting

Examples of Vitamin-K Foods Kale, Spinach, Broccoli, Turnip, Parsley, Cabbage, Banana, etc.

Can increase Blood pressure and should be avoided with drugs that Interfere with the breakdown of

Tyramine, such as Monoamine-Oxidase Inhibitors and Anti-Parkinson’s drugs. If used together, there is

increased risk of Hypertensive Crisis and Serotonin syndrome

Examples of Tyramine-containing Foods Aged cheese, Dried/Fermented meat, Wine/Bear, Dried

Pickle, Chocolate or smoked food

Patients taking Digoxin for Heart failure or ACEi / K-sparing diuretics for Blood pressure should be

careful with salts substitutes that replace Sodium with Potassium

Increased Potassium can decrease the effectiveness of Digoxin

Taking potassium supplements with drugs that increase potassium in the body, can lead to too much

potassium in the blood, which can cause abnormal heart rhythms (Arrhythmia)

Examples of Foods rich in Potassium Banana, Oranges, Green-leafy vegetables

Taking Salts high in Sodium can lead to Increase Blood pressure

It is important to know that both Sodium & Potassium have opposite effects – Sodium increases blood

pressure whereas potassium decreases blood pressure by relaxing blood vessels and excreting sodium =

So there should be a balance in the body as too much of either can be dangerous

Can lead to additive Drowsiness if used with following drugs Antihistamines (Diphenhydramine,

Brompheniramine, Chlorpheniramine, Cetirazine, etc.), Anti-depressants, Benzodiazepines, Stimulants,

Antipsychotics

Can lead to Stomach Ulcer/Bleeding and Liver damage if used with NSAIDs, APAP, Atomoxetine,

Statins,

Can lead to Impaired concentration and risk of Heart Problems if used with Stimulants

(Methylphenidate, Amphetamines)

Can lead to additive/abnormally low levels of Hypoglycemia with Antidiabetics

Can lead to dangerous side effects including Coma & Death if used with Narcotic Analgesics/Opioids

(Codeine, Morphine, Hydrocodone, Oxycodone)

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– used for indigestion/heartburn

Glycyrrhizin, a component of black licorice, can cause irregular heartbeat or even death when combined

with digoxin

Licorice also appears to make certain drugs less effective blood-pressure medications, blood

thinners, pain relievers, and birth-control pills

Don’t mix with Tetracyclines / Fluoroquinolones Can prevent the body from absorbing the drug. In

general, tetracycline works better if taken one hour before or two hours after eating

Just like Calcium, fiber can also bind to other drugs and Decreases their concentration

For example, patients with diabetes who try to decrease their cholesterol levels by eating oatmeal after

taking metformin might be worsening their diabetic control. Metformin blood levels are decreased when

taken with large amounts of fiber. Levothyroxine is another drug that is altered when taken with fiber.

Digoxin and penicillin are also affected by this food–drug interaction

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Drugs causing Lactic Acidosis

‘MINA’ – Metformin, INSTI, NRTI, ARTs

Drugs causing PML-Progressive Multifactorial Leukoencephalopathy

‘DiNa likes BeRi’ – Dimethyl fumarate, Natalizumab, Belimumab and Rituximab

Drugs needing Refrigeration after Reconstitution

Penicillins (Augmentin/Penicillin/Ampicillin), Cephalosporins (Except Cefdinir), Erythromycin and

Vancomycin/Valacyclovir

Drugs needing 2 Forms of Birth control / Great Caution to not get Pregnant

‘LeRI’ – Lefluminide (Stay in the body until 6 months later), Ribavarin (Stay until 2 years later) and

Isotretinoin (IPLEDGE program)

Drugs Requiring Acidic pH for Adequate Absorption

‘CIA’ – Calcium carbonate, Iron and Azoles (Ketoconazole, Itraconazole, etc.)

Drugs causing Pulmonary Fibrosis

‘BNMAS’ – Bleomycin, Nitrofurantoin, Methotrexate, Amiodarone and Sulfasalazine

Drugs Increasing Uric Acid

‘DAT PRN’ – Diuretics, Aspirin (increase doses), Tacrolimus, Pyrazinamide, Ribavarin and Niacin

Drugs causing Gingival Hyperplasia

‘CPC’ – Calcium-channel blockers (Nifedipine, Verapamil, Diltiazem), Phenytoin and Cyclosporine

Drugs causing QT-Prolongation

‘4As & QM’ – Antipsychotics, Antidepressants, Antihistamines, Antiarrhythmic & Quinolones, Macrolides

Drugs Increasing PR-interval

‘BCD PL’ – Beta-blockers, Calcium channel blockers, Digoxin and Protease inhibitors, Lacosamide