http://clinfowiki.org/wiki/api.php?action=feedcontributions&user=AdamWright&feedformat=atomClinfowiki - User contributions [en]2024-03-29T05:18:40ZUser contributionsMediaWiki 1.22.4http://clinfowiki.org/wiki/index.php/Preventive_care_remindersPreventive care reminders2010-08-17T20:27:03Z<p>AdamWright: </p>
<hr />
<div> <p align="center" style='text-align:center'><b><u><span style='font-size:16.0pt'>Sample<br />
Reminders from the Clinical Decision Support Expert Panel</span></u></b></p><br />
<br />
<p align="center" style='text-align:center'><i><span style='font-size:16.0pt'>Based on<br />
content from the Partners HealthCare</span></i></p><br />
<br />
<p><i>&nbsp;</i></p><br />
<br />
<p><b><span style='font-family:Arial;color:red'>It is important to note that, although<br />
we make this content available in good faith (and use much of it ourselves), neither<br />
the expert panel, the CERT-HIT, Brigham and Women's Hospital,<br />
Partners HealthCare or the Agency for Healthcare Research and Quality guarantee this<br />
content; it is provided as is and must be reviewed for correctness<br />
and completeness by any potential user.</span></b></p><br />
<br />
<p>&nbsp;</p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p class="Arial"><b><span style='font-family:Arial'>Needs Pneumovax (age &gt; 65 and<br />
no Pneumovax ever)<br /><br />
<br /></span></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>142</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Vaccinations</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age &gt;<br />
65</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No Pneumovax on<br />
file</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order pneumovax</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Needs repeat<br />
pneumovax &gt;65<br /><br />
<br /></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>143</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Vaccinations</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age &gt;<br />
65</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND one (and only one) pneumovax on<br />
file</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>latest pneumovax was<br />
performed 5 years ago and when patient was less</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>than 65 years of age</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span>Order pneumovax</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Needs<br />
Pneumovax (high risk medical condition)<br /><br />
<br /></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>144</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Vaccinations</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age<br />
18-65</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient has a high risk medical<br />
condition</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No pneumovax on<br />
record</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order pneumovax</span></p><br />
</div><br />
<br />
<p align="center" style='text-align:center;text-autospace:none'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial;color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Repeat<br />
Pneumovax (high risk medical condition)<br /><br />
<br /></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>145</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Vaccinations</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Patient<br />
has high risk medical condition</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>One and Only One<br />
pneumovax given &gt;5 years ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Perform pneuomax</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; color:black;layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Influenza<br />
Vaccination Older Than 50<br /><br />
<br /></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>146</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Vaccinations</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age &gt;<br />
50</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Today is within flu<br />
season: Oct, Nov, Dec, Jan, Feb (Oct 1 to March</span> <span style=<br />
'font-size:10.0pt;color:black'>1), no previous vacc.</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Perform influenza vaccination.</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Needs<br />
Influenza Vaccination 18-50 (high risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>147</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Vaccinations</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age<br />
18-50</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient has a high risk medical<br />
condition</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Today is within flu season: Oct,<br />
Nov, Dec, Jan, Feb</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>NO Flu shot during<br />
the current flu season</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Influenza Vaccine concept ID:<br />
1516</span></p><br />
</div><b><u><span style=<br />
'font-size:10.0pt;font-family:"Times New Roman";color:black; text-transform:uppercase;layout-grid-mode:line'><br clear="all"<br />
style='page-break-before: always' /></span></u></b><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Osteoporosis<br />
Management for At-Risk Populations<br /><br />
<br /></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>148</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Osteoporosis<br />
Prevention</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>((Female<br />
at least 65 years) OR</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>(Female 50-64 has risk factors for<br />
osteoporosis [smoking, past smoking, prior fracture since age 45, use of oral<br />
glucocorticoids for &gt;=3 months or family history of osteoporosis))</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No osteoporosis meds<br />
on med list and no bone density scan on file</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span>Order bone densitometry</span></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
</div><br />
<br />
<p align="center" style='text-align:center;text-autospace:none'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial;color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Overdue for<br />
mammography (High FHx Risk)<br /><br />
<br /></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>149</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
A</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND High FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND age&gt;40 yrs, &lt;75<br />
yrs</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No mammogram in the<br />
past 12 months.</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Overdue for<br />
mammography (High FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>150</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
B</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND High FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is =&lt; 40 years and &gt;<br />
25 years</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND (Age of youngest affected (with<br />
Breast cancer) relative - patient's age) &lt; = 10 years<br />
)</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No mammogram in the<br />
past 12 months</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Overdue for<br />
mammography (Mod FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><span style=<br />
'font-size:10.0pt;color:black; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>151</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
A</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Mod FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient &gt;40 years, &lt;75<br />
yrs</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No mammogram in the<br />
past 12 months.</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span>Order m</span><span style='font-size:10.0pt;color:black'>ammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Overdue for<br />
mammography (Mod FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>152</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
B</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Mod FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is =&lt; 40 and &gt; 25<br />
years of age</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND(Age of youngest affected (with<br />
Breast cancer) relative - patient's age) &lt;= 10<br />
years)</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No mammogram in the<br />
past 12 months.</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><b><u><span style=<br />
'font-size:10.0pt;font-family:"Times New Roman";color:black; text-transform:uppercase;layout-grid-mode:line'><br clear="all"<br />
style='page-break-before: always' /></span></u></b><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Overdue for<br />
mammography (Average Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>153</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
A</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Avg FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is older than 40 years of<br />
age, &lt;75 yrs</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No mammogram in the<br />
past 12 months.</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span>Order m</span><span style='font-size:10.0pt;color:black'>ammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Almost due<br />
for mammography (High FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>155</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
A</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND High FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is older than 40 years of<br />
age, &lt;75 yrs</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last mammogram 10-12<br />
(inclusive) months ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Almost due<br />
for mammography (High FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>156</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
B</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND High FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is =&lt; 40 and &gt; 25<br />
years of age</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Age of youngest affected (with<br />
Breast cancer) relative - patient's age) &lt;= 10<br />
years)</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last mammogram 10-12<br />
(inclusive) months ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Almost due<br />
for mammography (Mod FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>157</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
A</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Mod FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND older than 40 years of age, &lt;75<br />
yrs</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last mammogram 10-12<br />
(inclusive) months ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Almost due<br />
for mammography (Mod FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>158</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
B</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Mod FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is =&lt; 40 and &gt; 25<br />
years of age</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Age of youngest affected (with<br />
Breast cancer) relative - patient's age) &lt;= 10 years</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last mammogram 10-12<br />
(inclusive) months ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><b><u><span style=<br />
'font-size:10.0pt;font-family:"Times New Roman";color:black; text-transform:uppercase;layout-grid-mode:line'><br clear="all"<br />
style='page-break-before: always' /></span></u></b><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Almost due<br />
for mammography (Average Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>159</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
A</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Avg FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is older than 40 years of<br />
age, &lt;75 yrs</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last mammogram 10-12<br />
(inclusive) months ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Overdue for<br />
pap smear</span></u></b></p><br />
<br />
<p><b><span style=<br />
'font-size:10.0pt;color:black;layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>161</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND age &gt; 18 and &lt; 65</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND hysterectomy and TAH-BSO not on<br />
problem list</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last pap &gt; 3<br />
years ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Perform pap</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; color:black;layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Almost due<br />
for pap smear</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>162</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND age &gt; 18 and &lt; 65</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND hysterectomy and TAH-BSO not on<br />
problem list</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last pap 2.5 - 3<br />
years ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Perform pap smear</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><span style=<br />
'font-size:10.0pt; color:black'>&nbsp;</span></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 1.0pt 1.0pt 1.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'>NO risk factors, almost due for<br />
Lipids Assessment (male)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>192</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span>Lipid</span> <span style=<br />
'font-size:10.0pt;color:black'>creening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age<br />
<b>&gt;35, &lt;80</b></span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not diabetic</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND no CHD and its<br />
equivalents</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND FHx for CHD is AVERAGE</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND problem list does not contain<br />
smoking and hypertension</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND <b>male</b></span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>RISK GROUP<br />
DEFINITION</span></u></span></b> <span style='font-size:10.0pt;color:black'>No total<br />
cholesterol in &gt;54 months or no previous data</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND No LDL in &gt;54 months or no<br />
previous data</span></p><br />
<br />
<p><b><span><u><span style=<br />
'color:black; text-transform:uppercase'>Recommendation</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Order lipid panel</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'></p><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 1.0pt 1.0pt 1.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'>NO risk factors, almost due for<br />
Lipids Assessment (female)</span></u></b></p><br />
<br />
<p><b><span style='font-size:10.0pt;color:black'>&nbsp;</span></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>193</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span>Lipid</span> <span style=<br />
'font-size:10.0pt;color:black'>creening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age<br />
<b>&gt;45, &lt;80</b></span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not diabetic</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND no CHD and its<br />
equivalents</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND FHx for CHD is AVERAGE</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND problem list does not contain<br />
smoking and hypertension</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND <b>female</b></span></p><br />
<br />
<p><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>AND</span><br />
<span style='font-size:10.0pt; color:black'>No total cholesterol in &gt;54 months or<br />
no previous data</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND No LDL in &gt;54 months or no<br />
previous data</span></p><br />
<br />
<p><b><span><u><span style=<br />
'color:black; text-transform:uppercase'>Recommendation</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Order lipid panel</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Literature/ref.</span></u></b></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>1. NCEP/ATP III. Executive Summary of<br />
the Third Report of the NCEP Expert Panel on Detection, Evaluation, and</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Treatment of High Blood Cholesterol in<br />
Adults (ATP III). JAMA, Vol 285 (19): 2486-2497.</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>2. USPSTF. Screening Adults for Lipid<br />
Disorders. Am J Prev Med. 2001; 20 (3S): 73-76.</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><span style=<br />
'font-size:10.0pt; color:black'>&nbsp;</span></p><span style=<br />
'font-size:10.0pt;font-family:"Times New Roman";color:black'><br clear="all" style=<br />
'page-break-before:always' /></span><br />
<br />
<p style='text-autospace:none'><span style=<br />
'font-size:10.0pt; color:black'>&nbsp;</span></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 1.0pt 1.0pt 1.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'>LMR Reminder: NO risk factors,<br />
Overdue for Lipids Assessment (Male)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>190</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span>Lipid</span> <span style=<br />
'font-size:10.0pt;color:black'>creening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age<br />
<b>&gt;35, &lt;80</b></span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not diabetic</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND no CHD and its<br />
equivalents</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND FHx for CHD is AVERAGE (change it<br />
to NOT(moderate or high)</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND problem list does not contain<br />
smoking and hypertension</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND <b>male</b></span></p><br />
<br />
<p><span>AND </span><span style='font-size:10.0pt;color:black'>no total cholesterol<br />
in &gt;5 years or no previous data</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND No LDL in &gt;5 years or no<br />
previous data</span></p><br />
<br />
<p><b><span><u><span style=<br />
'color:black; text-transform:uppercase'>Recommendation</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Order lipid panel</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 1.0pt 1.0pt 1.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'>LMR Reminder: NO risk factors,<br />
Overdue for Lipids Assessment (female)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>191</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span>Lipid</span> <span style=<br />
'font-size:10.0pt;color:black'>creening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age<br />
<b>&gt;45, &lt;80</b></span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not diabetic</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND no CHD and its<br />
equivalents</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND FHx for CHD is AVERAGE (change it<br />
to NOT(moderate or high)</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND problem list does not contain<br />
smoking and hypertension</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND <b>female</b></span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND </span><span style=<br />
'font-size: 10.0pt;color:black'>No total cholesterol in &gt;5 years or no previous<br />
data</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND No LDL in &gt;5 years or no<br />
previous data</span></p><br />
<br />
<p><b><span><u><span style=<br />
'color:black; text-transform:uppercase'>Recommendation</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Order lipid panel</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Literature/ref.</span></u></b></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>1. NCEP/ATP III. Executive Summary of<br />
the Third Report of the NCEP Expert Panel on Detection, Evaluation, and</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Treatment of High Blood Cholesterol in<br />
Adults (ATP III). JAMA, Vol 285 (19): 2486-2497.</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>2. USPSTF. Screening Adults for Lipid<br />
Disorders. Am J Prev Med. 2001; 20 (3S): 73-76.</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><span style=<br />
'font-size:10.0pt; color:black'>&nbsp;</span></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 1.0pt 1.0pt 1.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'>LMR Reminder: Risk Factor: Family<br />
History, Almost due for Lipids Assessment</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>188</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span>Lipid s</span><span style=<br />
'font-size:10.0pt;color:black'>creening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age&gt;20<br />
and &lt;80</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not diabetic</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not CHD equivalent</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND FHx risk for CHD is<br />
MODERATE</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND no total cholesterol or no previous<br />
data</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND No LDL or no previous data &gt; 54<br />
months</span></p><br />
<br />
<p><b><span><u><span style=<br />
'color:black; text-transform:uppercase'>Recommendation</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Order lipid panel</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 1.0pt 1.0pt 1.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'>LMR Reminder: Risk Factor: Family<br />
History, Almost due for Lipid Assessment</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>189</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span>Lipid s</span><span style=<br />
'font-size:10.0pt;color:black'>creening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age&gt;20<br />
and &lt;80</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not diabetic</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not CHD equivalent</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND problem list contains HTN OR<br />
smoking</span></p><br />
<br />
<p><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>AND</span><br />
<span style='font-size:10.0pt; color:black'>No total cholesterol in &gt;54 months or<br />
no previous data</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND No LDL in &gt;54 months or no<br />
previous data</span></p><br />
<br />
<p><b><span><u><span style=<br />
'color:black; text-transform:uppercase'>Recommendation</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Order lipid panel</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Literature/ref.</span></u></b></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>1. NCEP/ATP III. Executive Summary of<br />
the Third Report of the NCEP Expert Panel on Detection, Evaluation, and</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Treatment of High Blood Cholesterol in<br />
Adults (ATP III). JAMA, Vol 285 (19): 2486-2497.</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>2. USPSTF. Screening Adults for Lipid<br />
Disorders. Am J Prev Med. 2001; 20 (3S): 73-76.</span></p><br />
</div></div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Preventive_care_remindersPreventive care reminders2010-08-17T18:30:35Z<p>AdamWright: </p>
<hr />
<div> <p align="center" style='text-align:center'><b><u><span style='font-size:16.0pt'>Sample<br />
Reminders from the Clinical Decision Support Expert Panel</span></u></b></p><br />
<br />
<p align="center" style='text-align:center'><i><span style='font-size:16.0pt'>Based on<br />
content from the Partners HealthCare</span></i></p><br />
<br />
<p><i>&nbsp;</i></p><br />
<br />
<p><b><span style='font-family:Arial;color:red'>It is important to note that, although<br />
we make this content available in good faith (and use much of it ourselves), neither<br />
the expert panel, the CERT-HIT, Brigham and Women&acirc;&euro;&trade;s Hospital,<br />
Partners HealthCare or the Agency for Healthcare Research and Quality guarantee this<br />
content &acirc;&euro;&ldquo; it is provided as is and must be reviewed for correctness<br />
and completeness by any potential user.</span></b></p><br />
<br />
<p>&nbsp;</p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p class="Arial"><b><span style='font-family:Arial'>Needs Pneumovax (age &gt; 65 and<br />
no Pneumovax ever)<br /><br />
<br /></span></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>142</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Vaccinations</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age &gt;<br />
65</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No Pneumovax on<br />
file</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order pneumovax</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Needs repeat<br />
pneumovax &gt;65<br /><br />
<br /></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>143</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Vaccinations</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age &gt;<br />
65</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND one (and only one) pneumovax on<br />
file</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>latest pneumovax was<br />
performed 5 years ago and when patient was less</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>than 65 years of age</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span>Order pneumovax</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Needs<br />
Pneumovax (high risk medical condition)<br /><br />
<br /></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>144</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Vaccinations</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age<br />
18-65</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient has a high risk medical<br />
condition</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No pneumovax on<br />
record</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order pneumovax</span></p><br />
</div><br />
<br />
<p align="center" style='text-align:center;text-autospace:none'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial;color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Repeat<br />
Pneumovax (high risk medical condition)<br /><br />
<br /></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>145</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Vaccinations</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Patient<br />
has high risk medical condition</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>One and Only One<br />
pneumovax given &gt;5 years ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Perform pneuomax</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; color:black;layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Influenza<br />
Vaccination Older Than 50<br /><br />
<br /></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>146</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Vaccinations</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age &gt;<br />
50</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Today is within flu<br />
season: Oct, Nov, Dec, Jan, Feb (Oct 1 to March</span> <span style=<br />
'font-size:10.0pt;color:black'>1), no previous vacc.</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Perform influenza vaccination.</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Needs<br />
Influenza Vaccination 18-50 (high risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>147</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Vaccinations</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age<br />
18-50</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient has a high risk medical<br />
condition</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Today is within flu season: Oct,<br />
Nov, Dec, Jan, Feb</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>NO Flu shot during<br />
the current flu season</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Influenza Vaccine concept ID:<br />
1516</span></p><br />
</div><b><u><span style=<br />
'font-size:10.0pt;font-family:"Times New Roman";color:black; text-transform:uppercase;layout-grid-mode:line'><br clear="all"<br />
style='page-break-before: always' /></span></u></b><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Osteoporosis<br />
Management for At-Risk Populations<br /><br />
<br /></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>148</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Osteoporosis<br />
Prevention</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>((Female<br />
at least 65 years) OR</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>(Female 50-64 has risk factors for<br />
osteoporosis [smoking, past smoking, prior fracture since age 45, use of oral<br />
glucocorticoids for &gt;=3 months or family history of osteoporosis))</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No osteoporosis meds<br />
on med list and no bone density scan on file</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span>Order bone densitometry</span></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
</div><br />
<br />
<p align="center" style='text-align:center;text-autospace:none'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial;color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Overdue for<br />
mammography (High FHx Risk)<br /><br />
<br /></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>149</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
A</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND High FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND age&gt;40 yrs, &lt;75<br />
yrs</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No mammogram in the<br />
past 12 months.</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Overdue for<br />
mammography (High FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>150</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
B</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND High FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is =&lt; 40 years and &gt;<br />
25 years</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND (Age of youngest affected (with<br />
Breast cancer) relative - patient&acirc;&euro;&trade;s age) &lt; = 10 years<br />
)</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No mammogram in the<br />
past 12 months</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Overdue for<br />
mammography (Mod FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><span style=<br />
'font-size:10.0pt;color:black; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>151</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
A</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Mod FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient &gt;40 years, &lt;75<br />
yrs</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No mammogram in the<br />
past 12 months.</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span>Order m</span><span style='font-size:10.0pt;color:black'>ammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Overdue for<br />
mammography (Mod FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>152</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
B</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Mod FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is =&lt; 40 and &gt; 25<br />
years of age</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND(Age of youngest affected (with<br />
Breast cancer) relative - patient&acirc;&euro;&trade;s age) &lt;= 10<br />
years)</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No mammogram in the<br />
past 12 months.</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><b><u><span style=<br />
'font-size:10.0pt;font-family:"Times New Roman";color:black; text-transform:uppercase;layout-grid-mode:line'><br clear="all"<br />
style='page-break-before: always' /></span></u></b><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Overdue for<br />
mammography (Average Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>153</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
A</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Avg FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is older than 40 years of<br />
age, &lt;75 yrs</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>No mammogram in the<br />
past 12 months.</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span>Order m</span><span style='font-size:10.0pt;color:black'>ammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Almost due<br />
for mammography (High FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>155</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
A</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND High FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is older than 40 years of<br />
age, &lt;75 yrs</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last mammogram 10-12<br />
(inclusive) months ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Almost due<br />
for mammography (High FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>156</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
B</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND High FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is =&lt; 40 and &gt; 25<br />
years of age</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Age of youngest affected (with<br />
Breast cancer) relative - patient&acirc;&euro;&trade;s age) &lt;= 10<br />
years)</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last mammogram 10-12<br />
(inclusive) months ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Almost due<br />
for mammography (Mod FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>157</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
A</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Mod FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND older than 40 years of age, &lt;75<br />
yrs</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last mammogram 10-12<br />
(inclusive) months ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Almost due<br />
for mammography (Mod FHx Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>158</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
B</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Mod FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is =&lt; 40 and &gt; 25<br />
years of age</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Age of youngest affected (with<br />
Breast cancer) relative - patient&acirc;&euro;&trade;s age) &lt;= 10 years</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last mammogram 10-12<br />
(inclusive) months ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><b><u><span style=<br />
'font-size:10.0pt;font-family:"Times New Roman";color:black; text-transform:uppercase;layout-grid-mode:line'><br clear="all"<br />
style='page-break-before: always' /></span></u></b><br />
<br />
<p style='text-autospace:none'><b><u><span style=<br />
'font-size: 10.0pt;color:black;text-transform:uppercase;layout-grid-mode:line'><span style='text-decoration:none'><br />
&nbsp;</span></span></u></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Almost due<br />
for mammography (Average Risk)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>159</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Rule<br />
A</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Avg FHx Risk of Breast<br />
cancer</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Bilateral Mastectomy NOT on problem<br />
list</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND Patient is older than 40 years of<br />
age, &lt;75 yrs</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last mammogram 10-12<br />
(inclusive) months ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Order mammogram</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Overdue for<br />
pap smear</span></u></b></p><br />
<br />
<p><b><span style=<br />
'font-size:10.0pt;color:black;layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>161</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND age &gt; 18 and &lt; 65</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND hysterectomy and TAH-BSO not on<br />
problem list</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last pap &gt; 3<br />
years ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Perform pap</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; color:black;layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'>Almost due<br />
for pap smear</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black;layout-grid-mode:line'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>162</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span style='font-size:10.0pt;color:black'>Cancer<br />
Screening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style=<br />
'font-size:10.0pt;color:black'>Female</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND age &gt; 18 and &lt; 65</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND hysterectomy and TAH-BSO not on<br />
problem list</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation<br />
Logic:</span></u></b> <span style='font-size:10.0pt;color:black'>Last pap 2.5 - 3<br />
years ago</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Recommendation</span></u></b><br />
<span style='font-size:10.0pt;color:black'>Perform pap smear</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><span style=<br />
'font-size:10.0pt; color:black'>&nbsp;</span></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 1.0pt 1.0pt 1.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'>NO risk factors, almost due for<br />
Lipids Assessment (male)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>192</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span>Lipid</span> <span style=<br />
'font-size:10.0pt;color:black'>creening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age<br />
<b>&gt;35, &lt;80</b></span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not diabetic</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND no CHD and its<br />
equivalents</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND FHx for CHD is AVERAGE</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND problem list does not contain<br />
smoking and hypertension</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND <b>male</b></span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>RISK GROUP<br />
DEFINITION</span></u></span></b> <span style='font-size:10.0pt;color:black'>No total<br />
cholesterol in &gt;54 months or no previous data</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND No LDL in &gt;54 months or no<br />
previous data</span></p><br />
<br />
<p><b><span><u><span style=<br />
'color:black; text-transform:uppercase'>Recommendation</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Order lipid panel</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'></p><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 1.0pt 1.0pt 1.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'>NO risk factors, almost due for<br />
Lipids Assessment (female)</span></u></b></p><br />
<br />
<p><b><span style='font-size:10.0pt;color:black'>&nbsp;</span></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>193</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span>Lipid</span> <span style=<br />
'font-size:10.0pt;color:black'>creening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age<br />
<b>&gt;45, &lt;80</b></span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not diabetic</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND no CHD and its<br />
equivalents</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND FHx for CHD is AVERAGE</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND problem list does not contain<br />
smoking and hypertension</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND <b>female</b></span></p><br />
<br />
<p><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>AND</span><br />
<span style='font-size:10.0pt; color:black'>No total cholesterol in &gt;54 months or<br />
no previous data</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND No LDL in &gt;54 months or no<br />
previous data</span></p><br />
<br />
<p><b><span><u><span style=<br />
'color:black; text-transform:uppercase'>Recommendation</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Order lipid panel</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Literature/ref.</span></u></b></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>1. NCEP/ATP III. Executive Summary of<br />
the Third Report of the NCEP Expert Panel on Detection, Evaluation, and</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Treatment of High Blood Cholesterol in<br />
Adults (ATP III). JAMA, Vol 285 (19): 2486-2497.</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>2. USPSTF. Screening Adults for Lipid<br />
Disorders. Am J Prev Med. 2001; 20 (3S): 73-76.</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><span style=<br />
'font-size:10.0pt; color:black'>&nbsp;</span></p><span style=<br />
'font-size:10.0pt;font-family:"Times New Roman";color:black'><br clear="all" style=<br />
'page-break-before:always' /></span><br />
<br />
<p style='text-autospace:none'><span style=<br />
'font-size:10.0pt; color:black'>&nbsp;</span></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 1.0pt 1.0pt 1.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'>LMR Reminder: NO risk factors,<br />
Overdue for Lipids Assessment (Male)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>190</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span>Lipid</span> <span style=<br />
'font-size:10.0pt;color:black'>creening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age<br />
<b>&gt;35, &lt;80</b></span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not diabetic</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND no CHD and its<br />
equivalents</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND FHx for CHD is AVERAGE (change it<br />
to NOT(moderate or high)</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND problem list does not contain<br />
smoking and hypertension</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND <b>male</b></span></p><br />
<br />
<p><span>AND </span><span style='font-size:10.0pt;color:black'>no total cholesterol<br />
in &gt;5 years or no previous data</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND No LDL in &gt;5 years or no<br />
previous data</span></p><br />
<br />
<p><b><span><u><span style=<br />
'color:black; text-transform:uppercase'>Recommendation</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Order lipid panel</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><b><span style=<br />
'font-size:10.0pt; layout-grid-mode:line'>&nbsp;</span></b></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 1.0pt 1.0pt 1.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'>LMR Reminder: NO risk factors,<br />
Overdue for Lipids Assessment (female)</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>191</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span>Lipid</span> <span style=<br />
'font-size:10.0pt;color:black'>creening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age<br />
<b>&gt;45, &lt;80</b></span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not diabetic</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND no CHD and its<br />
equivalents</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND FHx for CHD is AVERAGE (change it<br />
to NOT(moderate or high)</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND problem list does not contain<br />
smoking and hypertension</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND <b>female</b></span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND </span><span style=<br />
'font-size: 10.0pt;color:black'>No total cholesterol in &gt;5 years or no previous<br />
data</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND No LDL in &gt;5 years or no<br />
previous data</span></p><br />
<br />
<p><b><span><u><span style=<br />
'color:black; text-transform:uppercase'>Recommendation</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Order lipid panel</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Literature/ref.</span></u></b></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>1. NCEP/ATP III. Executive Summary of<br />
the Third Report of the NCEP Expert Panel on Detection, Evaluation, and</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Treatment of High Blood Cholesterol in<br />
Adults (ATP III). JAMA, Vol 285 (19): 2486-2497.</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>2. USPSTF. Screening Adults for Lipid<br />
Disorders. Am J Prev Med. 2001; 20 (3S): 73-76.</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'><span style=<br />
'font-size:10.0pt; color:black'>&nbsp;</span></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 1.0pt 1.0pt 1.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'>LMR Reminder: Risk Factor: Family<br />
History, Almost due for Lipids Assessment</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>188</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span>Lipid s</span><span style=<br />
'font-size:10.0pt;color:black'>creening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age&gt;20<br />
and &lt;80</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not diabetic</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not CHD equivalent</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND FHx risk for CHD is<br />
MODERATE</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND no total cholesterol or no previous<br />
data</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND No LDL or no previous data &gt; 54<br />
months</span></p><br />
<br />
<p><b><span><u><span style=<br />
'color:black; text-transform:uppercase'>Recommendation</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Order lipid panel</span></p><br />
</div><br />
<br />
<p style='text-autospace:none'></p><br />
<br />
<div style='border:solid windowtext 1.0pt;padding:1.0pt 1.0pt 1.0pt 1.0pt'><br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'>LMR Reminder: Risk Factor: Family<br />
History, Almost due for Lipid Assessment</span></u></b></p><br />
<br />
<p align="center" style=<br />
'text-align:center;text-autospace:none; border:none;padding:0in'><b><u><span style=<br />
'font-size:10.0pt;font-family:Arial; color:black'><span style=<br />
'text-decoration:none'>&nbsp;</span></span></u></b></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Rule#:</span></u><br />
<span style='color:black'>189</span> <u><span style=<br />
'color:black;text-transform:uppercase'>Rule category</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Health Maintenance</span><br />
<b><span><u><span style='color:black;text-transform:uppercase'>Primary Clinical<br />
Area</span></u></span></b> <span>Lipid s</span><span style=<br />
'font-size:10.0pt;color:black'>creening</span></p><br />
<br />
<p><b><span><u><span style='color:black; text-transform:uppercase'>Risk Group<br />
Definition</span></u></span></b> <span style='font-size:10.0pt;color:black'>Age&gt;20<br />
and &lt;80</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not diabetic</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND not CHD equivalent</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND problem list contains HTN OR<br />
smoking</span></p><br />
<br />
<p><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>AND</span><br />
<span style='font-size:10.0pt; color:black'>No total cholesterol in &gt;54 months or<br />
no previous data</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>AND No LDL in &gt;54 months or no<br />
previous data</span></p><br />
<br />
<p><b><span><u><span style=<br />
'color:black; text-transform:uppercase'>Recommendation</span></u></span></b><br />
<span style='font-size:10.0pt;color:black'>Order lipid panel</span></p><br />
<br />
<p><b><u><span style=<br />
'font-size:10.0pt;color:black;text-transform:uppercase;layout-grid-mode: line'>Literature/ref.</span></u></b></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>1. NCEP/ATP III. Executive Summary of<br />
the Third Report of the NCEP Expert Panel on Detection, Evaluation, and</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>Treatment of High Blood Cholesterol in<br />
Adults (ATP III). JAMA, Vol 285 (19): 2486-2497.</span></p><br />
<br />
<p><span style='font-size:10.0pt;color:black'>2. USPSTF. Screening Adults for Lipid<br />
Disorders. Am J Prev Med. 2001; 20 (3S): 73-76.</span></p><br />
</div></div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Preventive_care_remindersPreventive care reminders2010-08-17T18:05:13Z<p>AdamWright: </p>
<hr />
<div>Loading</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Preventive_care_remindersPreventive care reminders2010-08-17T18:04:41Z<p>AdamWright: </p>
<hr />
<div>'''Sample Reminders from the Clinical Decision Support Expert Panel'''<br />
''Based on content from the Partners HealthCare''<br />
<br />
'''It is important to note that, although we make this content available in good faith (and use much of it ourselves), neither the expert panel, the CERT-HIT, Brigham and Women\’s Hospital, Partners HealthCare or the Agency for Healthcare Research and Quality guarantee this content – it is provided as is and must be reviewed for correctness and completeness by any potential user.'''<br />
<br />
<u>'''Needs Pneumovax (age > 65 and no Pneumovax ever)<br />
'''</u><br />
''' Rule\#: 142 Rule category '''Health Maintenance''' Primary Clinical Area '''Vaccinations<br />
''' Risk Group Definition '''Age > 65<br />
'''Recommendation Logic: '''No Pneumovax on file<br />
'''Recommendation '''Order pneumovax<br />
<br />
'''Needs repeat pneumovax >65<br />
'''<br />
''' Rule\#: 143 Rule category '''Health Maintenance''' Primary Clinical Area '''Vaccinations<br />
''' Risk Group Definition '''Age > 65 <br />
''' '''AND one (and only one) pneumovax on file''' '''<br />
'''Recommendation Logic: '''latest pneumovax was performed 5 years ago and when patient was less<br />
''' ''' than 65 years of age<br />
'''Recommendation '''Order pneumovax <br />
<br />
'''Needs Pneumovax (high risk medical condition)<br />
'''<br />
''' Rule\#: 144 Rule category '''Health Maintenance''' Primary Clinical Area '''Vaccinations<br />
''' Risk Group Definition '''Age 18-65<br />
''' '''AND Patient has a high risk medical condition<br />
'''Recommendation Logic: '''No pneumovax on record<br />
'''Recommendation '''Order pneumovax<br />
<br />
'''Repeat Pneumovax (high risk medical condition)<br />
'''<br />
''' Rule\#: 145 Rule category '''Health Maintenance''' Primary Clinical Area '''Vaccinations<br />
''' Risk Group Definition '''Patient has high risk medical condition<br />
'''Recommendation Logic: '''One and Only One pneumovax given >5 years ago<br />
'''Recommendation '''Perform pneuomax<br />
<br />
'''Influenza Vaccination Older Than 50<br />
'''<br />
''' Rule\#: 146 Rule category '''Health Maintenance''' Primary Clinical Area '''Vaccinations<br />
''' Risk Group Definition '''Age > 50<br />
'''Recommendation Logic: '''Today is within flu season: Oct, Nov, Dec, Jan, Feb (Oct 1 to March ''' '''1), no previous vacc.<br />
'''Recommendation '''Perform influenza vaccination.<br />
<br />
'''Needs Influenza Vaccination 18-50 (high risk)'''<br />
<br />
''' Rule\#: 147 Rule category '''Health Maintenance''' Primary Clinical Area '''Vaccinations<br />
''' Risk Group Definition '''Age 18-50 <br />
''' '''AND Patient has a high risk medical condition<br />
''' '''AND Today is within flu season: Oct, Nov, Dec, Jan, Feb<br />
'''Recommendation Logic: '''NO Flu shot during the current flu season<br />
'''Recommendation '''Influenza Vaccine concept ID: 1516<br />
''' <br />
'''<br />
'''Osteoporosis Management for At-Risk Populations<br />
'''<br />
''' Rule\#: 148 Rule category '''Health Maintenance''' Primary Clinical Area '''Osteoporosis Prevention<br />
''' Risk Group Definition '''((Female at least 65 years) OR <br />
''' '''(Female 50-64 has risk factors for osteoporosis \[smoking, past smoking, prior fracture since age 45, use of oral glucocorticoids for >=3 months or family history of osteoporosis))<br />
'''Recommendation Logic: '''No osteoporosis meds on med list and no bone density scan on file<br />
'''Recommendation '''Order bone densitometry <br />
<br />
<br />
'''Overdue for mammography (High FHx Risk)<br />
'''<br />
''' Rule\#: 149 Rule category '''Health Maintenance''' Primary Clinical Area '''Cancer Screening<br />
''' Risk Group Definition '''Rule A<br />
''' '''Female <br />
''' '''AND High FHx Risk of Breast cancer <br />
''' '''AND Bilateral Mastectomy NOT on problem list <br />
''' '''AND age>40 yrs, <75 yrs<br />
'''Recommendation Logic: '''No mammogram in the past 12 months.<br />
'''Recommendation '''Order mammogram <br />
<br />
'''Overdue for mammography (High FHx Risk)'''<br />
<br />
''' Rule\#: 150 Rule category '''Health Maintenance''' Primary Clinical Area '''Cancer Screening<br />
''' Risk Group Definition '''Rule B<br />
''' '''Female<br />
''' '''AND High FHx Risk of Breast cancer <br />
''' '''AND Bilateral Mastectomy NOT on problem list <br />
''' '''AND Patient is =< 40 years and > 25 years <br />
''' '''AND (Age of youngest affected (with Breast cancer) relative - patient\’s age) < = 10 years )<br />
'''Recommendation Logic: '''No mammogram in the past 12 months<br />
'''Recommendation '''Order mammogram<br />
<br />
'''Overdue for mammography (Mod FHx Risk)'''<br />
<br />
''' Rule\#: 151 Rule category '''Health Maintenance''' Primary Clinical Area '''Cancer Screening<br />
''' Risk Group Definition '''Rule A<br />
''' '''Female <br />
''' '''AND Mod FHx Risk of Breast cancer <br />
''' '''AND Bilateral Mastectomy NOT on problem list <br />
''' '''AND Patient >40 years, <75 yrs<br />
'''Recommendation Logic: '''No mammogram in the past 12 months.<br />
'''Recommendation '''Order''' '''mammogram<br />
<br />
'''Overdue for mammography (Mod FHx Risk)'''<br />
<br />
''' Rule\#: 152 Rule category '''Health Maintenance''' Primary Clinical Area '''Cancer Screening<br />
''' Risk Group Definition '''Rule B<br />
''' '''Female <br />
''' '''AND Mod FHx Risk of Breast cancer <br />
''' '''AND Bilateral Mastectomy NOT on problem list <br />
''' '''AND Patient is =< 40 and > 25 years of age <br />
''' '''AND(Age of youngest affected (with Breast cancer) relative - patient\’s age) <= 10 years)<br />
'''Recommendation Logic: '''No mammogram in the past 12 months.<br />
'''Recommendation '''Order mammogram<br />
<br />
<br />
<br />
''' <br />
'''<br />
'''Overdue for mammography (Average Risk)'''<br />
<br />
''' Rule\#: 153 Rule category '''Health Maintenance''' Primary Clinical Area '''Cancer Screening<br />
''' Risk Group Definition '''Rule A<br />
''' '''Female <br />
''' '''AND Avg FHx Risk of Breast cancer <br />
''' '''AND Bilateral Mastectomy NOT on problem list <br />
''' '''AND Patient is older than 40 years of age, <75 yrs<br />
'''Recommendation Logic: '''No mammogram in the past 12 months.<br />
'''Recommendation '''Order mammogram<br />
<br />
'''Almost due for mammography (High FHx Risk)'''<br />
<br />
''' Rule\#: 155 Rule category '''Health Maintenance''' Primary Clinical Area '''Cancer Screening<br />
''' Risk Group Definition '''Rule A <br />
''' '''Female <br />
''' '''AND High FHx Risk of Breast cancer <br />
''' '''AND Bilateral Mastectomy NOT on problem list <br />
''' '''AND Patient is older than 40 years of age, <75 yrs<br />
'''Recommendation Logic: '''Last mammogram 10-12 (inclusive) months ago<br />
'''Recommendation '''Order mammogram<br />
<br />
'''Almost due for mammography (High FHx Risk)'''<br />
<br />
''' Rule\#: 156 Rule category '''Health Maintenance''' Primary Clinical Area '''Cancer Screening<br />
''' Risk Group Definition '''Rule B<br />
''' '''Female <br />
''' '''AND High FHx Risk of Breast cancer <br />
''' '''AND Bilateral Mastectomy NOT on problem list <br />
''' '''AND Patient is =< 40 and > 25 years of age <br />
''' '''AND Age of youngest affected (with Breast cancer) relative - patient\’s age) <= 10 years)<br />
'''Recommendation Logic: '''Last mammogram 10-12 (inclusive) months ago<br />
'''Recommendation '''Order mammogram<br />
<br />
'''Almost due for mammography (Mod FHx Risk)'''<br />
<br />
''' Rule\#: 157 Rule category '''Health Maintenance''' Primary Clinical Area '''Cancer Screening<br />
''' Risk Group Definition '''Rule A <br />
''' '''Female <br />
''' '''AND Mod FHx Risk of Breast cancer <br />
''' '''AND Bilateral Mastectomy NOT on problem list <br />
''' '''AND older than 40 years of age, <75 yrs<br />
'''Recommendation Logic: '''Last mammogram 10-12 (inclusive) months ago<br />
'''Recommendation '''Order mammogram<br />
<br />
'''Almost due for mammography (Mod FHx Risk)'''<br />
<br />
''' Rule\#: 158 Rule category '''Health Maintenance''' Primary Clinical Area '''Cancer Screening<br />
''' Risk Group Definition '''Rule B<br />
''' '''Female <br />
''' '''AND Mod FHx Risk of Breast cancer <br />
''' '''AND Bilateral Mastectomy NOT on problem list <br />
''' '''AND Patient is =< 40 and > 25 years of age <br />
''' '''AND Age of youngest affected (with Breast cancer) relative - patient\’s age) <= 10 years<br />
'''Recommendation Logic: '''Last mammogram 10-12 (inclusive) months ago<br />
'''Recommendation '''Order mammogram<br />
''' <br />
'''<br />
'''Almost due for mammography (Average Risk)'''<br />
<br />
''' Rule\#: 159 Rule category '''Health Maintenance''' Primary Clinical Area '''Cancer Screening<br />
''' Risk Group Definition '''Rule A <br />
''' '''Female <br />
''' '''AND Avg FHx Risk of Breast cancer <br />
''' '''AND Bilateral Mastectomy NOT on problem list <br />
''' '''AND Patient is older than 40 years of age, <75 yrs<br />
'''Recommendation Logic: '''Last mammogram 10-12 (inclusive) months ago<br />
'''Recommendation '''Order mammogram<br />
<br />
'''Overdue for pap smear'''<br />
<br />
''' Rule\#: 161 Rule category '''Health Maintenance''' Primary Clinical Area '''Cancer Screening<br />
''' Risk Group Definition '''Female <br />
''' '''AND age > 18 and < 65 <br />
''' '''AND hysterectomy and TAH-BSO not on problem list<br />
'''Recommendation Logic: '''Last pap > 3 years ago<br />
'''Recommendation '''Perform pap<br />
<br />
'''Almost due for pap smear'''<br />
<br />
''' Rule\#: 162 Rule category '''Health Maintenance''' Primary Clinical Area '''Cancer Screening<br />
''' Risk Group Definition '''Female <br />
''' '''AND age > 18 and < 65 <br />
''' '''AND hysterectomy and TAH-BSO not on problem list<br />
'''Recommendation Logic: '''Last pap 2.5 - 3 years ago<br />
'''Recommendation '''Perform pap smear<br />
<br />
'''NO risk factors, almost due for Lipids Assessment (male)'''<br />
<br />
''' Rule\#: 192 Rule category '''Health Maintenance''' Primary Clinical Area '''Lipid creening<br />
''' Risk Group Definition '''Age '''>35, <80'''<br />
''' '''AND not diabetic <br />
''' '''AND no CHD and its equivalents <br />
''' '''AND FHx for CHD is AVERAGE <br />
''' '''AND problem list does not contain smoking and hypertension <br />
''' '''AND '''male'''<br />
''' RISK GROUP DEFINITION '''No total cholesterol in >54 months or no previous data<br />
''' '''AND No LDL in >54 months or no previous data<br />
''' Recommendation '''Order lipid panel<br />
''' '''<br />
<br />
'''NO risk factors, almost due for Lipids Assessment (female)'''<br />
<br />
''' Rule\#: 193 Rule category '''Health Maintenance''' Primary Clinical Area '''Lipid creening<br />
''' Risk Group Definition '''Age '''>45, <80'''<br />
''' '''AND not diabetic <br />
''' '''AND no CHD and its equivalents <br />
''' '''AND FHx for CHD is AVERAGE <br />
''' '''AND problem list does not contain smoking and hypertension <br />
''' '''AND '''female'''<br />
AND No total cholesterol in >54 months or no previous data<br />
''' '''AND No LDL in >54 months or no previous data<br />
''' Recommendation '''Order lipid panel<br />
'''Literature/ref.'''<br />
''' '''1. NCEP/ATP III. Executive Summary of the Third Report of the NCEP Expert Panel on Detection, Evaluation, and <br />
''' '''Treatment of High Blood Cholesterol in Adults (ATP III). JAMA, Vol 285 (19): 2486-2497.<br />
''' '''2. USPSTF. Screening Adults for Lipid Disorders. Am J Prev Med. 2001; 20 (3S): 73-76.<br />
<br />
<br />
<br />
'''LMR Reminder: NO risk factors, Overdue for Lipids Assessment (Male)'''<br />
<br />
''' Rule\#: 190 Rule category '''Health Maintenance''' Primary Clinical Area '''Lipid creening<br />
''' Risk Group Definition '''Age '''>35, <80'''<br />
''' '''AND not diabetic <br />
''' '''AND no CHD and its equivalents <br />
''' '''AND FHx for CHD is AVERAGE (change it to NOT(moderate or high)<br />
''' '''AND problem list does not contain smoking and hypertension <br />
''' '''AND '''male'''<br />
''' '''AND''' '''no total cholesterol in >5 years or no previous data<br />
''' '''AND No LDL in >5 years or no previous data<br />
''' Recommendation '''Order lipid panel<br />
<br />
'''LMR Reminder: NO risk factors, Overdue for Lipids Assessment (female)'''<br />
<br />
''' Rule\#: 191 Rule category '''Health Maintenance''' Primary Clinical Area '''Lipid creening<br />
''' Risk Group Definition '''Age '''>45, <80'''<br />
''' '''AND not diabetic <br />
''' '''AND no CHD and its equivalents <br />
''' '''AND FHx for CHD is AVERAGE (change it to NOT(moderate or high)<br />
''' '''AND problem list does not contain smoking and hypertension <br />
''' '''AND''' female'''<br />
''' '''AND''' '''No total cholesterol in >5 years or no previous data<br />
''' '''AND No LDL in >5 years or no previous data<br />
''' Recommendation '''Order lipid panel<br />
'''Literature/ref.'''<br />
''' '''1. NCEP/ATP III. Executive Summary of the Third Report of the NCEP Expert Panel on Detection, Evaluation, and <br />
''' '''Treatment of High Blood Cholesterol in Adults (ATP III). JAMA, Vol 285 (19): 2486-2497.<br />
''' '''2. USPSTF. Screening Adults for Lipid Disorders. Am J Prev Med. 2001; 20 (3S): 73-76.<br />
<br />
'''LMR Reminder: Risk Factor: Family History, Almost due for Lipids Assessment'''<br />
<br />
''' Rule\#: 188 Rule category '''Health Maintenance''' Primary Clinical Area '''Lipid screening<br />
''' Risk Group Definition '''Age>20 and <80 <br />
''' '''AND not diabetic <br />
''' '''AND not CHD equivalent <br />
''' ''' AND FHx risk for CHD is MODERATE<br />
''' '''AND no total cholesterol or no previous data<br />
''' '''AND No LDL or no previous data > 54 months<br />
''' Recommendation '''Order lipid panel<br />
''' '''<br />
'''LMR Reminder: Risk Factor: Family History, Almost due for Lipid Assessment'''<br />
<br />
''' Rule\#: 189 Rule category '''Health Maintenance''' Primary Clinical Area '''Lipid screening<br />
''' Risk Group Definition '''Age>20 and <80 <br />
''' '''AND not diabetic <br />
''' '''AND not CHD equivalent <br />
''' '''AND problem list contains HTN OR smoking<br />
AND No total cholesterol in >54 months or no previous data<br />
''' '''AND No LDL in >54 months or no previous data<br />
''' Recommendation '''Order lipid panel<br />
'''Literature/ref.'''<br />
''' '''1. NCEP/ATP III. Executive Summary of the Third Report of the NCEP Expert Panel on Detection, Evaluation, and <br />
''' '''Treatment of High Blood Cholesterol in Adults (ATP III). JAMA, Vol 285 (19): 2486-2497.<br />
''' '''2. USPSTF. Screening Adults for Lipid Disorders. Am J Prev Med. 2001; 20 (3S): 73-76.</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/CDSCDS2010-08-17T17:57:30Z<p>AdamWright: /* Sample Decision Support Content */</p>
<hr />
<div>==Clinical Decision Support -- CDS==<br />
<br />
===Overview===<br />
<br />
Clinical Decision Support (CDS) refers broadly to providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care. Clinical knowledge of interest could range from simple facts and relationships to best practices for managing patients with specific disease states, new medical knowledge from clinical research and other types of information.<br />
<br />
For an overview of the process that healthcare organizations can use to begin, or improve, a clinical decision support (CDS) initiative interested parties can follow the guidelines described in <br />
[http://www.himss.org/ASP/topics_cds_workbook.asp?faid=108&tid=14 Improving Outcomes with Clinical Decision Suppport: An Implementer's Guide] to measurably improve key healthcare outcomes such as the quality, safety, and cost-effectiveness of care delivery.<br />
<br />
*[[National Roadmap for Clinical Decision Support]]<br />
*[[History of decision support]]<br />
*[[General system features associated with improvements in clinical practice]]<br />
*[http://wellness.wikispaces.com/Tactic+-+Support+Decisions+with+Diagnostic+Aids Support Decisions with Diagnostic Aids]<br />
*[[Clinical Decision Support Liability]]<br />
<br />
===[[Modes of Interaction]]===<br />
*[[Interpretation]]<br />
*[[Consultation]]<br />
*[[Monitoring]]<br />
*[[Critiquing]]<br />
*[[Teaching]]<br />
<br />
===[[Order Sets]]===<br />
*[[Personal Order Sets]]<br />
*[[Functional Specifications]]<br />
*[[Criteria for creating new order sets]]<br />
*[[A Process for Creating and Maintaining Order Sets]]<br />
*[[Most commonly used Order Sets in In-patient Setting]]<br />
<br />
===[[Information Resources]]===<br />
*[[http://himssclinicaldecisionsupportwiki.pbworks.com/ The HIMSS Clinical Decision Support (CDS) Task Force wiki]]<br />
*[[Alerts and Reminders]]<br />
*[[Alert Fatigue]]?<br />
*[[Alert placement in clinical workflow]]<br />
*[[Initial Selection of What to Alert on...]]<br />
*[[Alerts versus on-demand CDS]]<br />
*[[Sources of clinical decision support content]]<br />
<br />
===Artificial intelligence===<br />
<br />
Artificial intelligence is a system that was developed by a team of system engineers and clinicians. The system would take some of the workload from medical teams by assisting the physicians with tasks like diagnosis & Therapy recommendations. An AI system could be running within electronic medical record system, and alert a clinician when it detects a contraindication to a planned treatment. It could also alert the clinician when it detected patterns in clinical data that suggested significant changes in a patient’s condition.<br />
The definition of artificial intelligence has changed over the years, since 1956 till now. It is mostly found in data rich areas like intensive care settings<br />
There are many different types of clinical task to which Artificial intelligence can be applied.<br />
1. Monitoring patients vital signs and then evaluating and administering the right amounts of different drugs needed<br />
2. Planning an adequate nutritional support for maintaining the metabolic needs of newborn infants. Control of the level of pressure support ventilation.<br />
3. Reading of the electrocardiogram (ECG).<br />
<br />
There are numerous reasons why more expert systems are not in routine use. Some require the existence of an electronic medical record system to supply their data and most institutions do not yet have all their working data available electronically. Much of the difficulty has been the poor way in which they have fitted into clinical practice, which required additional effort from already busy individuals.<br />
<br />
Examples of AI that are still in practice <br />
samrtcare/pc ventilator manager, 2004.<br />
VIE-PNN Neo-natal parentral nutrition 1993. <br />
Examples of decommissioned AI are:<br />
N‘eoGaneshVentilator manager, 1992.<br />
ACORN Coronary care admission ,1987.<br />
By Bassima Hammoud<br />
[[category:BMI-512-W-08]]<br />
<br />
===Business Intelligence and Data Warehousing===<br />
*[[Business Intelligence & Data Warehousing for Healthcare]]<br />
*[[Clinical Data Warehousing]]<br />
<br />
===Medication-related Clinical Decision Support===<br />
<br />
<br />
Basic Medication-Related Decision Support<br />
*[[Drug-Allergy Interactions]]<br />
*Basic Dosing Guidance for medications in CPOE<br />
*Formulary Decision Support<br />
*Duplicate Therapy Checking<br />
*[[Drug-Drug interaction]]<br />
<br />
Advanced Medication-Related Decision Support<br />
*Advanced Dosing Guidance in CPOE<br />
*[[Drug-Laboratory Interactions]]<br />
*Advanced Checking of Drug-Disease Interactinos and Contraindications<br />
*[[Medications to be avoided in the elderly]]<br />
*[[Medications requiring dosage adjustments in renal insufficiency]]<br />
*[[Medications requiring dosage adjustments in hepatic disease]]<br />
*[[Medications to be avoided during pregnancy]]<br />
*[[Medications to be avoided while breastfeeding]]<br />
*[[Vaccination contraindications]]<br />
*[[Common Corollary orders]]<br />
*[[Drug-Food Interactions]]<br />
*[[Drug-Tobacco Interactions]]<br />
<br />
Adverse Drug Events<br />
*[[Detection of Adverse Mediation-Related Events]]<br />
<br />
<br />
<br />
*[[ List of 39 Warning Messages Targeting Prescribing Decisions Designed to Prevent Adverse Drug Events in Long-Term Care]]<br />
<br />
===Non-Medication-Based Safety Rules===<br />
* [[Diagnosis-Order Rules]]<br />
<br />
===Validation and Verification of Clinical Decision Support===<br />
*[[On Validation and Verification Of Decision Support Protocol Subsystems During Implementation-Optimization: Encapsulating P(X)]]<br />
<br />
===Sample Decision Support Content===<br />
* [[Diabetes CDS Content]]<br />
* [[Drug-Drug Interaction Rules]]<br />
* [[Clinical Reminders from Beth Israel/Deaconess Medical Center]] in Boston <br />
* Symptom Triage Decision Support for Consumers (example: "Chest Pain") [http://www.freemd.com/fmdTriage.html?e=Chest%20Pain]<br />
* [[Weight-based Heparin Dosing Guidelines]]<br />
* [[Flowchart-based decision support sample content]]<br />
* [[Preventive care reminders]]</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug_classesDrug classes2008-02-21T17:24:40Z<p>AdamWright: fixed alpha order</p>
<hr />
<div>'''ACE INHIBITORS'''<br />
* BENAZEPRIL<br />
* CAPTOPRIL<br />
* ENALAPRIL MALEATE<br />
* ENALAPRILAT<br />
* LISINOPRIL<br />
* MOEXIPRIL<br />
* QUINAPRIL<br />
* RAMIPRIL<br />
* TRANDOLAPRIL<br />
<br />
<br />
'''AMINOGLYCOSIDES'''<br />
* AMIKACIN<br />
* GENTAMICIN<br />
* KANAMYCIN<br />
* NEOMYCIN<br />
* NETILMICIN<br />
* PAROMOMYCIN<br />
* STREPTOMYCIN<br />
* TOBRAMYCIN<br />
<br />
<br />
'''AZOLE ANTIFUNGALS'''<br />
* CLOTRIMAZOLE<br />
* FLUCONAZOLE<br />
* ITRACONAZOLE<br />
* KETOCONAZOLE<br />
* MICONAZOLE<br />
<br />
<br />
'''BENZODIAZEPINES'''<br />
* ALPRAZOLAM<br />
* CHLORDIAZEPOXIDE<br />
* CLONAZEPAM<br />
* CLORAZEPATE DIPOTASSIUM<br />
* DIAZEPAM<br />
* FLURAZEPAM<br />
* LORAZEPAM<br />
* MIDAZOLAM<br />
* OXAZEPAM<br />
* TEMAZEPAM<br />
* TRIAZOLAM<br />
<br />
<br />
'''BETA BLOCKERS'''<br />
* ACEBUTOLOL<br />
* ATENOLOL<br />
* BETAXOLOL<br />
* BISOPROLOL FUMARATE<br />
* CARVEDILOL<br />
* ESMOLOL<br />
* LABETALOL<br />
* METOPROLOL<br />
* NADOLOL<br />
* PINDOLOL<br />
* PROPRANOLOL<br />
* SOTALOL<br />
* TIMOLOL<br />
<br />
<br />
'''CALCIUM CHANNEL BLOCKERS'''<br />
* AMLODIPINE BESYLATE<br />
* DILTIAZEM<br />
* FELODIPINE<br />
* ISRADIPINE<br />
* NICARDIPINE<br />
* NIFEDIPINE<br />
* NISOLDIPINE<br />
* VERAPAMIL<br />
<br />
<br />
'''COMT INHIBITORS'''<br />
* ENTACAPONE<br />
* LEVODOPA<br />
* TOLCAPONE<br />
<br />
<br />
'''HMG COA REDUCTASE INHIBITORS'''<br />
* ATORVASTATIN<br />
* CERIVASTATIN<br />
* FLUVASTATIN<br />
* LOVASTATIN<br />
* PRAVASTATIN<br />
* SIMVASTATIN<br />
<br />
<br />
'''MACROLIDES'''<br />
* AZITHROMYCIN<br />
* CLARITHROMYCIN<br />
* DIRITHROMYCIN<br />
* ERYHTROMYCIN BASE<br />
* ERYTHROMYCIN ESTOLATE<br />
* ERYTHROMYCIN ETHYLSUCCINATE<br />
* ERYTHROMYCIN GLUCEPTATE<br />
* ERYTHROMYCIN LACTOBIONATE<br />
* ERYTHROMYCIN STEARATE<br />
* TROLEANDOMYCIN<br />
<br />
<br />
'''MAO INHIBITORS'''<br />
* ISOCARBOXAZID<br />
* PHENELZINE<br />
* SELEGELINE<br />
* TRANYLCYPROMINE<br />
<br />
<br />
'''NARCOTICS'''<br />
* CODEINE<br />
* FENTANYL<br />
* HYDROMORPHONE<br />
* MEPERIDINE<br />
* METHADONE<br />
* MORPHINE<br />
* OXYCODONE<br />
* OXYMORPHONE<br />
* PROPOXYPHENE<br />
<br />
<br />
'''NM BLOCKERS'''<br />
* ATRACURIUM BESYLATE<br />
* CISATRACURIUM BESYLATE<br />
* DOXACURIUM CHLORIDE<br />
* MIVACURIUM CHLORIDE<br />
* PANCURONIUM BROMIDE<br />
* PIPECURONIUM BROMIDE<br />
* RAPACURONIUM BROMIDE<br />
* ROCURONIUM BROMIDE<br />
* SUCCINYLCHOLINE CHLORIDE<br />
* TUBOCURARINE CHLORIDE<br />
* VECURONIUM BROMIDE<br />
<br />
<br />
'''NSAIDs'''<br />
* IBUPROFEN<br />
* INDOMETHACIN<br />
* KETOROLAC<br />
* TROMETHAMINE<br />
* NAPROXEN<br />
* PIROXICAM<br />
<br />
<br />
'''POTASSIUM'''<br />
* POTASSIUM ACETATE<br />
* POTASSIUM BICARBONATE/CIT AC<br />
* POTASSIUM CHLORIDE<br />
* POTASSIUM IODIDE<br />
* POTASSIUM PHOS,M-BASIC-D-BASIC<br />
<br />
<br />
'''POTASSIUM SPARING DIURETICS'''<br />
* AMILORIDE<br />
* SPIRONOLACTONE<br />
* TRIAMTERENE<br />
<br />
<br />
'''PROTEASE INHIBITORS'''<br />
* AMPRENAVIR<br />
* INDINAVIR<br />
* MIGLITOL<br />
* RITONAVIR<br />
* SAQUINAVIR<br />
<br />
<br />
'''QUINOLONES'''<br />
* CIPROFLOXACIN<br />
* ENOXACIN<br />
* GREPAFLOXACIN<br />
* LEVOFLOXACIN<br />
* LOMEFLOXACIN<br />
* NORFLOXACIN<br />
* OFLOXACIN<br />
* SPARFLOXACIN<br />
* TROVAFLOXACIN MESYLATE<br />
<br />
<br />
'''SSRI ANTIDEPRESSANTS'''<br />
* CITALOPRAM<br />
* FLUOXETINE<br />
* FLUVAOXAMINE MALEATE<br />
* PAROXETINE<br />
* SERTRALINE<br />
<br />
<br />
'''SYMPATHOMIMETIC AGENTS'''<br />
* DOBUTAMINE<br />
* DOPAMINE<br />
* EPHEDRINE<br />
* EPINEPHRINE<br />
* ISOPROTERENOL<br />
* MIDODRINE<br />
* NOREPINEPHRINE<br />
* PHENYLEPHRINE<br />
* PSEUDOEPHEDRINE<br />
* TERBUTALINE<br />
<br />
<br />
'''TRICYCLIC ANTIDEPRESSANTS'''<br />
* AMITRIPTYLINE<br />
* AMOXAPINE<br />
* CLOMIPRAMINE<br />
* DESIPRAMINE<br />
* DOXEPIN<br />
* IMIPRAMINE<br />
* NORTRIPTYLINE<br />
* PROTRIPTYLINE<br />
* TRIMIPRAMINE MALEATE<br />
<br />
[[Category: CDS]]</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug-Drug_Interaction_RulesDrug-Drug Interaction Rules2008-02-20T20:43:50Z<p>AdamWright: </p>
<hr />
<div>These drug interactions are based on a set released by the Beth-Israel Deaconess Hospital, and are used here with permission. [http://geekdoctor.blogspot.com/2008/02/provider-order-entry.html (1)] [http://mycourses.med.harvard.edu/ec_res/nt/8AD4BE90-283F-4A6A-AADB-9F0DB529FA1E/drugdrug.doc (2)]. Several of the interactions refer to [[drug classes]], which are defined on the [[drug classes]] page.<br />
<br />
<table border="1" cellpadding="1" cellspacing="2"><br />
<tr><br />
<td><font size="2"><b>Generic Drug Name or Category</b></font></td><br />
<br />
<td><font size="2"><b>Interacts With</b></font></td><br />
<br />
<td><font size="2"><b>Severity</b></font></td><br />
<br />
<td><font size="2"><b>Text</b></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">POTASSIUM-SPARING DIURETICS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Diuretics and ACE inhibitors used together may cause hypotension. The<br />
combination of ACE inhibitors and potassium-sparing diuretics may cause significant<br />
hyperkalemia. This effect is particularly significant in patients with renal<br />
insufficiency.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">POTASSIUM [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">ACE inhibitors may decrease aldosterone causing hyperkalemia. When ACE<br />
inhibitors are coadministered with potassium-containing products, the risk of<br />
hyperkalemia is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">AZATHIOPRINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Allopurinol inhibits the metabolism of oral azathioprine, increasing<br />
serum azathioprine levels. Concomitant use can cause marked bone marrow suppression. If<br />
these drugs must be used together, azathioprine oral doses should be reduced to 25-30% of<br />
the usual dosage and the patient should be monitored closely for toxicity. Intravenous<br />
azathioprine does not appear to be affected by allopurinol.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Concurrent use of allopurinol and theophylline may result in<br />
theophylline toxicity (nausea, vomiting, palpitations, seizures). This interaction is<br />
more likely to occur with daily allopurinol doses of 600 mg or more.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Reports suggest that amiodarone may interfere with the clearance of<br />
cyclosporine. The risk of cyclosporine toxicity may increase.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may increase serum digoxin concentrations by up to 100%.<br />
Amiodarone may increase intestinal transit time, reduce renal clearance of digoxin,<br />
inhibit hepatic metabolism of digoxin, displace digoxin from protein-binding sites, and,<br />
in some cases, induce hypothyroidism. Empirical reduction or discontinuation of digoxin<br />
should be considered. Management also consists of monitoring clinical response or<br />
checking serum digoxin levels if toxicity is suspected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may inhibit hepatic metabolism of warfarin. A 30% to 50%<br />
reduction in warfarin dosage is recommended, as is frequent monitoring of<br />
INR.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some azoles, particulary Ketoconazole and Itraconazole, may inhibit<br />
the hepatic metabolism of cyclosporine. Serum cyclosporine concentrations and<br />
nephrotoxicity may increase fourfold. Cyclosporine dosage reductions of 80% have been<br />
necessary in some patients.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The use of HMG-CoA reductase inhibitors during azole therapy may<br />
increase CK, AST, ALT, and LDH serum levels.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">BETA BLOCKERS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of these drugs may cause severe bradycardia, cardiac<br />
arrest, or ventricular fibrillation. Use extreme caution using these drugs<br />
together.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The concomitant use of calcium channel blockers and beta-blockers can<br />
occasionally cause AV heart block and left-ventricular dysfunction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL BLOCKERS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase levels of calcium channel<br />
blockers. Be careful using this combination of drugs, and monitor for<br />
toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CIMETIDINE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Cimetidine inhibits the hepatic metabolism of warfarin, and may<br />
increase its anticoagulant effect over a one to two week period. If given together, the<br />
INR should be monitored, and the lowest possible dose of cimetidine should be used.<br />
Another histamine-2 antagonist may be used with less risk of interaction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CLOPIDOGREL BISULFATE</font></td><br />
<br />
<td><font size="2">NSAIDs [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The coadministration of nonsteroidal antiinflammatory drugs (NSAIDs)<br />
and clopidogrel should be undertaken with extreme caution. The coadministration of<br />
clopidogrel with naproxen resulted in occult gastrointestinal blood loss in healthy<br />
volunteers. The mechanism may be due to additive platelet inhibition. Additionally,<br />
diclofenac, ibuprofen, naproxen, mefenamic acid, indomethacin and piroxicam are<br />
substrates for the cytochrome P450 isoenzyme 2C9 inhibited by clopidogrel. The clinical<br />
magnitude of this interaction is not known. The clinician should observe the patient for<br />
increased NSAID toxicity if these agents are co-administered with<br />
clopidogrel.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">MACROLIDES [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may significantly increase cyclosporine<br />
serum concentrations, possibly by inhibiting hepatic metabolism of cyclosporine,<br />
resulting in nephrotoxicity. Appropriate monitoring of cyclosporine serum concentrations<br />
during co-administration is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">FOSCARNET SODIUM</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Foscarnet and cyclosporine used together may increase the risk of<br />
nephrotoxicity and renal failure. If these agents are used concomitantly, consider close<br />
observation of renal function and discontinue foscarnet if needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with high doses of Gemfibrozil can<br />
cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with moderate to high doses of HMG CoA<br />
reductase inhibitors can cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL<br><br />
DILTIAZEM</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil and Diltiazem may inhibit the hepatic metabolism of<br />
cyclosporine causing increased trough and steady state levels, and the risk of<br />
nephrotoxicity. Cyclosporine levels should be monitored, and dosage should be adjusted as<br />
needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DAPSONE</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Saquinavir may competitively inhibit the metabolism of drugs that are<br />
substrates of the cytochrome P-450 (3A4) microsomal enzymatic pathway. Plasma levels of<br />
these drugs may be elevated. The patient should be monitored closely for toxicities and<br />
lower dosages of these drugs may be necessary</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">MACROLIDES [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Theoretically this interaction might occur with other macrolides.<br />
Patients should be closely monitored for evidence of digoxin toxicity if macrolide<br />
antibiotics and digoxin must be coadministered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The addition of itraconazole to patients stabilized on digoxin has<br />
resulted in two to fourfold increases in serum digoxin concentrations and digoxin<br />
toxicity. The mechanism is unknown. The onset of toxicity generally occurs within 9 to 13<br />
days after the start of itraconazole therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">QUINIDINE<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine significantly increases serum digoxin levels in more than<br />
90% of patients. The mechanism is related to reduced renal and biliary clearance, and<br />
reduced volume of digoxin distribution. Empiric reduction in digoxin dosing may be<br />
considered at the initiation of combination therapy. Modifications in dosage should be<br />
expected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">TETRACYCLINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Tetracyclines may increase serum levels of orally administered digoxin<br />
in about 10% of the population. The mechanism may be related to changes in intestinal<br />
flora that alter the absorption of digoxin. If these drugs must be used together, the<br />
patient should be closely monitored for digoxin toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil increases digoxin levels significantly in most patients.<br />
This important and possibly severe interaction is related to several complex mechanisms.<br />
Digoxin and verapamil have additive effects in slowing AV conduction. Verapamil also<br />
decreases the elimination of digoxin. If verapamil and digoxin are used together to<br />
control a supraventricular tachyarrhythmia, the dosage of each drug may have to be<br />
reduced.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">CLARITHROMYCIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Efavirenz increases the metabolism of clarithromycin. No dosage<br />
adjustment is recommended when these drugs are co-administered, but a rash occurs in 46%<br />
of patients administered clarithromycin and efavirenz concomitantly. Alternative therapy<br />
such as azithromycin might be considered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">INDINAVIR SULFATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Coadministration of efavirenz and indinavir causes a decreased<br />
indinavir level. The mechanism of this interaction is hepatic enzyme induction of CYP3A4<br />
by efavirenz. The dosage of indinavir should be increased from 800 mg every 8 hours to<br />
1000 mg every 8 hours when these drugs are administered concomitantly.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ENOXAPARIN<br><br />
DALTEPARIN<br><br />
TINZAPARIN</font></td><br />
<br />
<td><font size="2">HEPARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Dalteparin may increase the risk of bleeding from heparin. The<br />
mechanism is additive inhibition of thrombin and factor Xa. If these agents must be used<br />
together, extreme caution is advised, and the patient should be monitored for signs of<br />
bleeding. Other low-molecular-weight heparins (LMWHs) may interact with heparin in a<br />
similar manner.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">KETOROLAC</font></td><br />
<br />
<td><font size="2">NSAIDs [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ketorolac is contraindicated in patients concurrently receiving<br />
aspirin or NSAIDs because of the cumulative risks of inducing serious NSAID-related<br />
adverse events (peptic ulcers, gastrointestinal bleeding and/or perforation).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MACROLIDES [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">When lovastatin and some macrolide antibiotics (erythromycin) have<br />
been used concomitantly in severely ill patients, severe myopathy and rhabdomyolysis have<br />
resulted. The mechanism appears to be inhibition of lovastatin metabolism by the<br />
macrolide. Patients should be instructed to report symptoms of muscle pain, weakness, or<br />
tenderness. If symptoms occur, creatine kinase should be measured. If creatine kinase is<br />
elevated, the drugs should be discontinued. A similar reaction may occur with other<br />
HMG-CoA reductase inhibitors.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">FENTANYL</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase fentanyl plasma levels. Patients<br />
should be closely observed for toxicity if these drugs are used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Gemfibrozil and lovastatin used together can cause severe myopathy and<br />
rhabdomyolysis. Combined use of gemfibrozil or clofibrate with other HMG-CoA reductase<br />
inhibitors may increase the risk of this side effect as well. If this combination must be<br />
used, the patient should be instructed to report symptoms of muscular pain, weakness, or<br />
tenderness. If creatine kinase is elevated, the drugs should be discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Immediate onset of excitement, sweating, rigidity, and hypertension<br />
can occur when monoamine oxidase inhibitors (MAOIs) are used concurrently with<br />
meperidine. Death has been reported. Similar effects have been reported with propoxyphene<br />
and fentanyl, but not with other analgesics. The combination of narcotic analgesics and<br />
MAOIs should be avoided if possible. An MAOI plus meperidine should not be used under any<br />
circumstances.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">COMT INHIBITORS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) stop the catalyst enzyme<br />
catechol-O-methyltransferase (COMT) from metabolizing levodopa to 3-O-methyldopa in the<br />
periphery, and in the brain.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">SSRI ANTIDEPRESSANTS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Severe and sometimes fatal reactions involving elevations in blood<br />
pressure, hyperthermia, rigidity, and autonomic instability have occurred in patients<br />
taking SSRIs in combination with monoamine oxidase inhibitors (MAOIs). A minimum period<br />
of two weeks should separate use of these drugs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">SYMPATHOMIMETIC AGENTS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sympathomimetic amines used with monoamine oxidase inhibitors may<br />
precipitate severe hypertensive reactions</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">TRICYCLIC ANTIDEPRESSANTS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants<br />
when used together may cause hyperpyretic crises, disseminated intravascular coagulation,<br />
convulsions, and death. The mechanism is unknown. Although these agents have been used<br />
together safely in many patients, some investigators recommend that tricyclic<br />
antidepressants not be used within two weeks of MAOIs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">VENLAFAXINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) used together with<br />
anti-depressants may cause severe, even fatal, reactions. The reactions reported with the<br />
newer antidepressants include hyperthermia, rigidity, myoclonus, autonomic instability,<br />
and mental status changes that range from delirium to coma. In general, MAOIs and<br />
venlafaxine or other SSRIs should be separated by 2 weeks.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NARCOTICS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">BENZODIAZEPINES [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Narcotics and benzodiazepines used together can cause excessive<br />
respiratory and CNS depression. The mechanism may be related in part to inhibition of<br />
hepatic oxidation of the benzodiazepine. Alprazolam has been most implicated in this<br />
interaction. Such interactions are more likely to occur in the benzodiazepine and<br />
narcotic "naive" patient.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NEVIRAPINE</font></td><br />
<br />
<td><font size="2">PROTEASE INHIBITORS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Because nevirapine may induce the hepatic P450 cytochrome system,<br />
reductions in plasma concentrations of protease inhibitors theoretically may occur. The<br />
manufacturer recommends that, until clinical studies provide information on dosage<br />
adjustments, protease inhibitors should not be administered concomitantly with<br />
nevirapine.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NIACIN</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Lovastatin and niacin used together may cause severe myopathy and<br />
rhabdomyolysis. Although this reaction has not been reported with concomitant use of<br />
pravastatin and niacin, patients should be instructed to report symptoms of muscle pain,<br />
weakness, or tenderness. If creatine kinase is elevated, the drugs should be<br />
discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">AMINOGLYCOSIDES [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Aminoglycoside antibiotics may potentiate the neuromuscular blockade<br />
caused by non-depolarizing muscle relaxants. The mechanism is presynaptic acetylcholine<br />
release and reduction of postsynaptic sensitivity to acetylcholine. These combinations<br />
should be avoided if possible.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">POLYMYXIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Polymyxin B may prolong apnea and respiratory paralysis after use of<br />
neuromuscular blocking agents. The mechanism may be related to decreased intracellular<br />
potassium or decreased ionized serum calcium. Intravenous calcium administration may be<br />
helpful in reversing the paralysis.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">There may be an increased risk of CNS or respiratory depression when<br />
this combination of drugs is used.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Phenytoin may significantly reduce cyclosporine serum concentrations.<br />
The mechanism may be inhibition of cyclosporine absorption or induction of hepatic<br />
metabolism or both. This interaction may occur with ethotoin, fosphenytoin, and<br />
mephenytoin as well. Cyclosporine levels should be closely monitored during concomitant<br />
therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Dilantin can accelerate the metabolism of ritonavir thus reducing its<br />
plasma concentration. Ritonavir can raise or lower dilantin levels. Use caution if these<br />
drugs must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">POTASSIUM [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">POTASSIUM-SPARING DIURETICS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of potassium-sparing diuretics and potassium<br />
preparations may result in hyperkalemia. These agents should not be used together unless<br />
the patient has documented hypokalemia while taking either agent alone. If this<br />
combination is used, the patient should be given dietary counseling and monitored very<br />
closely for hyperkalemia.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PROCAINAMIDE</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some beta-blockers may decrease the clearance and increase the serum<br />
level of procainamide. Data are available for metoprolol and propranolol<br />
only.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone can increase quinidine concentrations inducing prolongation<br />
of the QT interval. Quinidine dose may need to be reduced by 50% if amiodarone is<br />
added.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil may increase plasma quinidine concentrations. While these<br />
drugs can be given together safely, significant adverse side effects can occur,<br />
especially in patients with hypertrophic or dilated cardiomyopathies and in patients on<br />
higher doses of either drug. If these drugs must be given together, lower doses of<br />
quinidine are needed to achieve a given plasma concentration and clinical response.<br />
Clinical and electrocardiographic monitoring for quinidine toxicity (such as hypotension,<br />
arrhythmias, and AV block) is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may interfere with the metabolism of meperidine. Large<br />
increases in serum meperidine concentrations may result. The concomitant use of these<br />
agents is contraindicated by the manufacturer and should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir capsules and ritonavir oral solution contain alcohol, which<br />
may cause a reaction when this drug is used with disulfiram or metronidazole.<br />
Simultaneous use should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The plasma concentration of saquinavir mesylate (Invirase) is<br />
increased markedly (29-fold) by ritonavir. The safety of their concurrent use has not<br />
been established. The newer form of saquinavir (Fortovase) is more bioavailable.<br />
Therefore, this interaction is less relevant for saquinavir (Fortovase).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may cause large fluctuations in the serum concentrations of<br />
warfarin. If ritonavir and warfarin must be used together, frequent monitoring of the INR<br />
is strongly recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFADIAZINE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some sulfonamides inhibit the hepatic metabolism of phenytoin. Serum<br />
phenytoin levels and risk of toxicity may be increased. Data are available for<br />
sulfadiazine and sulfamethizole. Management consists of monitoring the patient for signs<br />
and symptoms of phenytoin toxicity, checking serum levels, and decreasing phenytoin<br />
dosage as necessary.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFAMETHOXAZOLE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sulfonamides increase the level of warfarin-(S) isomer by an unknown<br />
mechanism. Hypoprothrombinemic effect is enhanced. . Frequent monitoring of the INR is<br />
recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TACROLIMUS</font></td><br />
<br />
<td><font size="2">MACROLIDES [[Drug classes|(class)]]</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">In vitro and in vivo data suggest that erythromycin may inhibit the<br />
hepatic metabolism of tacrolimus. Data from two case reports suggest that concomitant use<br />
of erythromycin may result in elevated serum tacrolimus concentrations. If these drugs<br />
are used concomitantly, plasma tacrolimus concentrations should be carefully monitored,<br />
with reductions in dosage to prevent nephrotoxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">CIPROFLOXACIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ciprofloxacin can significantly reduce the clearance of theophylline<br />
by inhibition of hepatic metabolism. The interaction can result in theophylline toxicity,<br />
and may increase the risk of seizures, especially in the elderly. The patient should be<br />
monitored for theophylline toxicity and elevated serum levels while also taking<br />
ciprofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">MACROLIDES [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolides (erythromycin and troleandomycin) inhibit theophylline<br />
metabolism. During coadministration, serum theophylline levels and risk of theophylline<br />
toxicity are increased. Conversely, theophylline increases the renal clearance of<br />
erythromycin and decreases erythromycin concentrations. Monitoring of theophylline levels<br />
and efficacy is recommended when erythromycin is added to or discontinued from the<br />
patient's regimen. [Dirithromycin [?on formulary]appears to increase the plasma clearance<br />
of theophylline, and plasma theophylline concentrations can be decreased by approximately<br />
26%. The dirithromycin-theophylline interaction is unlikely to be clinically significant<br />
enough to modify treatment and outcome.] The effects of azithromycin and clarithromycin<br />
on the pharmacokinetic disposition of theophylline are not known. Azithromycin, however,<br />
does not appear to interfere with theophylline levels and may be the macrolide of choice<br />
for patients on theophylline therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with phenytoin may cause a 25% increase in<br />
phenytoin plasma concentration, particularly in patients receiving phenytoin twice a day.<br />
Additionally, the concentration of topiramate decreased by 48%. Addition or withdrawal of<br />
hydantoins during therapy with topiramate may require a dose adjustment of topiramate<br />
and/or the hydantoin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">VALPROATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with valproic acid may lead to an 11% decrease<br />
in valproic acid plasma concentration. Additionally, the concentration of topiramate<br />
decreased by 14%. The mechanism of action may be increased metabolism of both drugs.<br />
Addition or withdrawal of valproic acid during adjunctive therapy with topiramate may<br />
require a dose adjustment of topiramate and/or valproic acid.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE<br><br />
KETOCONAZOLE<br><br />
FLUCONAZOLE<br><br />
MICONAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">These drugs may increase the effect of warfarin. The mechanism is<br />
unknown. Close monitoring of the INR is recommended if these drugs must be used<br />
together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">CELECOXIB<br><br />
ROFECOXIB</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Risk of bleeding is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">MACROLIDES [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may inhibit the hepatic metabolism of<br />
warfarin resulting in an enhanced anticoagulant effect. Data are available for<br />
erythromycin and clarithromycin only. Close monitoring of the INR is recommended if a<br />
macrolide antimicrobial and warfarin must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Metronidazole may inhibit the metabolism of warfarin and increase its<br />
anticoagulant effect. The INR should be monitored closely.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Warfarin can increase phenytoin half-life and serum concentrations.<br />
The addition of phenytoin to warfarin therapy can increase the INR. The mechanism is not<br />
known. Serum phenytoin concentrations and INR should be monitored in patients receiving<br />
this combination.</font></td><br />
</tr><br />
<br />
<tr align="left"><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINOLONES[[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Most fluoroquinolones can inhibit the metabolism of warfarin<br />
increasing the INR. Patients on concomitant therapy should be monitored for elevations in<br />
INR. However, one study of sixteen volunteers reported a lack of interaction between<br />
warfarin and levofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine can induce hypoprothrombinemia, thus raising the INR and<br />
increasing the risk of bleeding.<br />
</td></tr></table></div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug-Drug_Interaction_RulesDrug-Drug Interaction Rules2008-02-20T20:43:24Z<p>AdamWright: </p>
<hr />
<div>These drug interactions are based on a set released by the Beth-Israel Deaconess Hospital, and are used here with permission. [http://geekdoctor.blogspot.com/2008/02/provider-order-entry.html (1)] [http://mycourses.med.harvard.edu/ec_res/nt/8AD4BE90-283F-4A6A-AADB-9F0DB529FA1E/drugdrug.doc (2)]. Several of the interactions refer to [[drug classes]], which are defined on the [[drug classes]] page.<br />
<br />
<table border="1" cellpadding="1" cellspacing="2"><br />
<tr><br />
<td><font size="2"><b>Generic Drug Name or Category</b></font></td><br />
<br />
<td><font size="2"><b>Interacts With</b></font></td><br />
<br />
<td><font size="2"><b>Severity</b></font></td><br />
<br />
<td><font size="2"><b>Text</b></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS [[Drug classes|(class)]]<br></font></td><br />
<br />
<td><font size="2">POTASSIUM-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Diuretics and ACE inhibitors used together may cause hypotension. The<br />
combination of ACE inhibitors and potassium-sparing diuretics may cause significant<br />
hyperkalemia. This effect is particularly significant in patients with renal<br />
insufficiency.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *</font></td><br />
<br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">ACE inhibitors may decrease aldosterone causing hyperkalemia. When ACE<br />
inhibitors are coadministered with potassium-containing products, the risk of<br />
hyperkalemia is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">AZATHIOPRINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Allopurinol inhibits the metabolism of oral azathioprine, increasing<br />
serum azathioprine levels. Concomitant use can cause marked bone marrow suppression. If<br />
these drugs must be used together, azathioprine oral doses should be reduced to 25-30% of<br />
the usual dosage and the patient should be monitored closely for toxicity. Intravenous<br />
azathioprine does not appear to be affected by allopurinol.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Concurrent use of allopurinol and theophylline may result in<br />
theophylline toxicity (nausea, vomiting, palpitations, seizures). This interaction is<br />
more likely to occur with daily allopurinol doses of 600 mg or more.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Reports suggest that amiodarone may interfere with the clearance of<br />
cyclosporine. The risk of cyclosporine toxicity may increase.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may increase serum digoxin concentrations by up to 100%.<br />
Amiodarone may increase intestinal transit time, reduce renal clearance of digoxin,<br />
inhibit hepatic metabolism of digoxin, displace digoxin from protein-binding sites, and,<br />
in some cases, induce hypothyroidism. Empirical reduction or discontinuation of digoxin<br />
should be considered. Management also consists of monitoring clinical response or<br />
checking serum digoxin levels if toxicity is suspected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may inhibit hepatic metabolism of warfarin. A 30% to 50%<br />
reduction in warfarin dosage is recommended, as is frequent monitoring of<br />
INR.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some azoles, particulary Ketoconazole and Itraconazole, may inhibit<br />
the hepatic metabolism of cyclosporine. Serum cyclosporine concentrations and<br />
nephrotoxicity may increase fourfold. Cyclosporine dosage reductions of 80% have been<br />
necessary in some patients.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The use of HMG-CoA reductase inhibitors during azole therapy may<br />
increase CK, AST, ALT, and LDH serum levels.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">BETA BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of these drugs may cause severe bradycardia, cardiac<br />
arrest, or ventricular fibrillation. Use extreme caution using these drugs<br />
together.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL *</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The concomitant use of calcium channel blockers and beta-blockers can<br />
occasionally cause AV heart block and left-ventricular dysfunction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase levels of calcium channel<br />
blockers. Be careful using this combination of drugs, and monitor for<br />
toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CIMETIDINE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Cimetidine inhibits the hepatic metabolism of warfarin, and may<br />
increase its anticoagulant effect over a one to two week period. If given together, the<br />
INR should be monitored, and the lowest possible dose of cimetidine should be used.<br />
Another histamine-2 antagonist may be used with less risk of interaction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CLOPIDOGREL BISULFATE</font></td><br />
<br />
<td><font size="2">NSAIDs *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The coadministration of nonsteroidal antiinflammatory drugs (NSAIDs)<br />
and clopidogrel should be undertaken with extreme caution. The coadministration of<br />
clopidogrel with naproxen resulted in occult gastrointestinal blood loss in healthy<br />
volunteers. The mechanism may be due to additive platelet inhibition. Additionally,<br />
diclofenac, ibuprofen, naproxen, mefenamic acid, indomethacin and piroxicam are<br />
substrates for the cytochrome P450 isoenzyme 2C9 inhibited by clopidogrel. The clinical<br />
magnitude of this interaction is not known. The clinician should observe the patient for<br />
increased NSAID toxicity if these agents are co-administered with<br />
clopidogrel.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may significantly increase cyclosporine<br />
serum concentrations, possibly by inhibiting hepatic metabolism of cyclosporine,<br />
resulting in nephrotoxicity. Appropriate monitoring of cyclosporine serum concentrations<br />
during co-administration is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">FOSCARNET SODIUM</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Foscarnet and cyclosporine used together may increase the risk of<br />
nephrotoxicity and renal failure. If these agents are used concomitantly, consider close<br />
observation of renal function and discontinue foscarnet if needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with high doses of Gemfibrozil can<br />
cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with moderate to high doses of HMG CoA<br />
reductase inhibitors can cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL<br><br />
DILTIAZEM</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil and Diltiazem may inhibit the hepatic metabolism of<br />
cyclosporine causing increased trough and steady state levels, and the risk of<br />
nephrotoxicity. Cyclosporine levels should be monitored, and dosage should be adjusted as<br />
needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DAPSONE</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Saquinavir may competitively inhibit the metabolism of drugs that are<br />
substrates of the cytochrome P-450 (3A4) microsomal enzymatic pathway. Plasma levels of<br />
these drugs may be elevated. The patient should be monitored closely for toxicities and<br />
lower dosages of these drugs may be necessary</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Theoretically this interaction might occur with other macrolides.<br />
Patients should be closely monitored for evidence of digoxin toxicity if macrolide<br />
antibiotics and digoxin must be coadministered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The addition of itraconazole to patients stabilized on digoxin has<br />
resulted in two to fourfold increases in serum digoxin concentrations and digoxin<br />
toxicity. The mechanism is unknown. The onset of toxicity generally occurs within 9 to 13<br />
days after the start of itraconazole therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">QUINIDINE<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine significantly increases serum digoxin levels in more than<br />
90% of patients. The mechanism is related to reduced renal and biliary clearance, and<br />
reduced volume of digoxin distribution. Empiric reduction in digoxin dosing may be<br />
considered at the initiation of combination therapy. Modifications in dosage should be<br />
expected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">TETRACYCLINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Tetracyclines may increase serum levels of orally administered digoxin<br />
in about 10% of the population. The mechanism may be related to changes in intestinal<br />
flora that alter the absorption of digoxin. If these drugs must be used together, the<br />
patient should be closely monitored for digoxin toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil increases digoxin levels significantly in most patients.<br />
This important and possibly severe interaction is related to several complex mechanisms.<br />
Digoxin and verapamil have additive effects in slowing AV conduction. Verapamil also<br />
decreases the elimination of digoxin. If verapamil and digoxin are used together to<br />
control a supraventricular tachyarrhythmia, the dosage of each drug may have to be<br />
reduced.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">CLARITHROMYCIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Efavirenz increases the metabolism of clarithromycin. No dosage<br />
adjustment is recommended when these drugs are co-administered, but a rash occurs in 46%<br />
of patients administered clarithromycin and efavirenz concomitantly. Alternative therapy<br />
such as azithromycin might be considered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">INDINAVIR SULFATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Coadministration of efavirenz and indinavir causes a decreased<br />
indinavir level. The mechanism of this interaction is hepatic enzyme induction of CYP3A4<br />
by efavirenz. The dosage of indinavir should be increased from 800 mg every 8 hours to<br />
1000 mg every 8 hours when these drugs are administered concomitantly.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ENOXAPARIN<br><br />
DALTEPARIN<br><br />
TINZAPARIN</font></td><br />
<br />
<td><font size="2">HEPARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Dalteparin may increase the risk of bleeding from heparin. The<br />
mechanism is additive inhibition of thrombin and factor Xa. If these agents must be used<br />
together, extreme caution is advised, and the patient should be monitored for signs of<br />
bleeding. Other low-molecular-weight heparins (LMWHs) may interact with heparin in a<br />
similar manner.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">KETOROLAC</font></td><br />
<br />
<td><font size="2">NSAIDs *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ketorolac is contraindicated in patients concurrently receiving<br />
aspirin or NSAIDs because of the cumulative risks of inducing serious NSAID-related<br />
adverse events (peptic ulcers, gastrointestinal bleeding and/or perforation).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">When lovastatin and some macrolide antibiotics (erythromycin) have<br />
been used concomitantly in severely ill patients, severe myopathy and rhabdomyolysis have<br />
resulted. The mechanism appears to be inhibition of lovastatin metabolism by the<br />
macrolide. Patients should be instructed to report symptoms of muscle pain, weakness, or<br />
tenderness. If symptoms occur, creatine kinase should be measured. If creatine kinase is<br />
elevated, the drugs should be discontinued. A similar reaction may occur with other<br />
HMG-CoA reductase inhibitors.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">FENTANYL</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase fentanyl plasma levels. Patients<br />
should be closely observed for toxicity if these drugs are used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Gemfibrozil and lovastatin used together can cause severe myopathy and<br />
rhabdomyolysis. Combined use of gemfibrozil or clofibrate with other HMG-CoA reductase<br />
inhibitors may increase the risk of this side effect as well. If this combination must be<br />
used, the patient should be instructed to report symptoms of muscular pain, weakness, or<br />
tenderness. If creatine kinase is elevated, the drugs should be discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Immediate onset of excitement, sweating, rigidity, and hypertension<br />
can occur when monoamine oxidase inhibitors (MAOIs) are used concurrently with<br />
meperidine. Death has been reported. Similar effects have been reported with propoxyphene<br />
and fentanyl, but not with other analgesics. The combination of narcotic analgesics and<br />
MAOIs should be avoided if possible. An MAOI plus meperidine should not be used under any<br />
circumstances.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">COMT INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) stop the catalyst enzyme<br />
catechol-O-methyltransferase (COMT) from metabolizing levodopa to 3-O-methyldopa in the<br />
periphery, and in the brain.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SSRI ANTIDEPRESSANTS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Severe and sometimes fatal reactions involving elevations in blood<br />
pressure, hyperthermia, rigidity, and autonomic instability have occurred in patients<br />
taking SSRIs in combination with monoamine oxidase inhibitors (MAOIs). A minimum period<br />
of two weeks should separate use of these drugs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SYMPATHOMIMETIC AGENTS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sympathomimetic amines used with monoamine oxidase inhibitors may<br />
precipitate severe hypertensive reactions</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">TRICYCLIC ANTIDEPRESSANTS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants<br />
when used together may cause hyperpyretic crises, disseminated intravascular coagulation,<br />
convulsions, and death. The mechanism is unknown. Although these agents have been used<br />
together safely in many patients, some investigators recommend that tricyclic<br />
antidepressants not be used within two weeks of MAOIs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">VENLAFAXINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) used together with<br />
anti-depressants may cause severe, even fatal, reactions. The reactions reported with the<br />
newer antidepressants include hyperthermia, rigidity, myoclonus, autonomic instability,<br />
and mental status changes that range from delirium to coma. In general, MAOIs and<br />
venlafaxine or other SSRIs should be separated by 2 weeks.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NARCOTICS *<br></font></td><br />
<br />
<td><font size="2">BENZODIAZEPINES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Narcotics and benzodiazepines used together can cause excessive<br />
respiratory and CNS depression. The mechanism may be related in part to inhibition of<br />
hepatic oxidation of the benzodiazepine. Alprazolam has been most implicated in this<br />
interaction. Such interactions are more likely to occur in the benzodiazepine and<br />
narcotic "naive" patient.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NEVIRAPINE</font></td><br />
<br />
<td><font size="2">PROTEASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Because nevirapine may induce the hepatic P450 cytochrome system,<br />
reductions in plasma concentrations of protease inhibitors theoretically may occur. The<br />
manufacturer recommends that, until clinical studies provide information on dosage<br />
adjustments, protease inhibitors should not be administered concomitantly with<br />
nevirapine.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NIACIN</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Lovastatin and niacin used together may cause severe myopathy and<br />
rhabdomyolysis. Although this reaction has not been reported with concomitant use of<br />
pravastatin and niacin, patients should be instructed to report symptoms of muscle pain,<br />
weakness, or tenderness. If creatine kinase is elevated, the drugs should be<br />
discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMINOGLYCOSIDES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Aminoglycoside antibiotics may potentiate the neuromuscular blockade<br />
caused by non-depolarizing muscle relaxants. The mechanism is presynaptic acetylcholine<br />
release and reduction of postsynaptic sensitivity to acetylcholine. These combinations<br />
should be avoided if possible.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">POLYMYXIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Polymyxin B may prolong apnea and respiratory paralysis after use of<br />
neuromuscular blocking agents. The mechanism may be related to decreased intracellular<br />
potassium or decreased ionized serum calcium. Intravenous calcium administration may be<br />
helpful in reversing the paralysis.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">There may be an increased risk of CNS or respiratory depression when<br />
this combination of drugs is used.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Phenytoin may significantly reduce cyclosporine serum concentrations.<br />
The mechanism may be inhibition of cyclosporine absorption or induction of hepatic<br />
metabolism or both. This interaction may occur with ethotoin, fosphenytoin, and<br />
mephenytoin as well. Cyclosporine levels should be closely monitored during concomitant<br />
therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Dilantin can accelerate the metabolism of ritonavir thus reducing its<br />
plasma concentration. Ritonavir can raise or lower dilantin levels. Use caution if these<br />
drugs must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">POTASSIUM-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of potassium-sparing diuretics and potassium<br />
preparations may result in hyperkalemia. These agents should not be used together unless<br />
the patient has documented hypokalemia while taking either agent alone. If this<br />
combination is used, the patient should be given dietary counseling and monitored very<br />
closely for hyperkalemia.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PROCAINAMIDE</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some beta-blockers may decrease the clearance and increase the serum<br />
level of procainamide. Data are available for metoprolol and propranolol<br />
only.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone can increase quinidine concentrations inducing prolongation<br />
of the QT interval. Quinidine dose may need to be reduced by 50% if amiodarone is<br />
added.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil may increase plasma quinidine concentrations. While these<br />
drugs can be given together safely, significant adverse side effects can occur,<br />
especially in patients with hypertrophic or dilated cardiomyopathies and in patients on<br />
higher doses of either drug. If these drugs must be given together, lower doses of<br />
quinidine are needed to achieve a given plasma concentration and clinical response.<br />
Clinical and electrocardiographic monitoring for quinidine toxicity (such as hypotension,<br />
arrhythmias, and AV block) is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may interfere with the metabolism of meperidine. Large<br />
increases in serum meperidine concentrations may result. The concomitant use of these<br />
agents is contraindicated by the manufacturer and should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir capsules and ritonavir oral solution contain alcohol, which<br />
may cause a reaction when this drug is used with disulfiram or metronidazole.<br />
Simultaneous use should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The plasma concentration of saquinavir mesylate (Invirase) is<br />
increased markedly (29-fold) by ritonavir. The safety of their concurrent use has not<br />
been established. The newer form of saquinavir (Fortovase) is more bioavailable.<br />
Therefore, this interaction is less relevant for saquinavir (Fortovase).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may cause large fluctuations in the serum concentrations of<br />
warfarin. If ritonavir and warfarin must be used together, frequent monitoring of the INR<br />
is strongly recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFADIAZINE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some sulfonamides inhibit the hepatic metabolism of phenytoin. Serum<br />
phenytoin levels and risk of toxicity may be increased. Data are available for<br />
sulfadiazine and sulfamethizole. Management consists of monitoring the patient for signs<br />
and symptoms of phenytoin toxicity, checking serum levels, and decreasing phenytoin<br />
dosage as necessary.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFAMETHOXAZOLE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sulfonamides increase the level of warfarin-(S) isomer by an unknown<br />
mechanism. Hypoprothrombinemic effect is enhanced. . Frequent monitoring of the INR is<br />
recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TACROLIMUS</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">In vitro and in vivo data suggest that erythromycin may inhibit the<br />
hepatic metabolism of tacrolimus. Data from two case reports suggest that concomitant use<br />
of erythromycin may result in elevated serum tacrolimus concentrations. If these drugs<br />
are used concomitantly, plasma tacrolimus concentrations should be carefully monitored,<br />
with reductions in dosage to prevent nephrotoxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">CIPROFLOXACIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ciprofloxacin can significantly reduce the clearance of theophylline<br />
by inhibition of hepatic metabolism. The interaction can result in theophylline toxicity,<br />
and may increase the risk of seizures, especially in the elderly. The patient should be<br />
monitored for theophylline toxicity and elevated serum levels while also taking<br />
ciprofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolides (erythromycin and troleandomycin) inhibit theophylline<br />
metabolism. During coadministration, serum theophylline levels and risk of theophylline<br />
toxicity are increased. Conversely, theophylline increases the renal clearance of<br />
erythromycin and decreases erythromycin concentrations. Monitoring of theophylline levels<br />
and efficacy is recommended when erythromycin is added to or discontinued from the<br />
patient's regimen. [Dirithromycin [?on formulary]appears to increase the plasma clearance<br />
of theophylline, and plasma theophylline concentrations can be decreased by approximately<br />
26%. The dirithromycin-theophylline interaction is unlikely to be clinically significant<br />
enough to modify treatment and outcome.] The effects of azithromycin and clarithromycin<br />
on the pharmacokinetic disposition of theophylline are not known. Azithromycin, however,<br />
does not appear to interfere with theophylline levels and may be the macrolide of choice<br />
for patients on theophylline therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with phenytoin may cause a 25% increase in<br />
phenytoin plasma concentration, particularly in patients receiving phenytoin twice a day.<br />
Additionally, the concentration of topiramate decreased by 48%. Addition or withdrawal of<br />
hydantoins during therapy with topiramate may require a dose adjustment of topiramate<br />
and/or the hydantoin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">VALPROATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with valproic acid may lead to an 11% decrease<br />
in valproic acid plasma concentration. Additionally, the concentration of topiramate<br />
decreased by 14%. The mechanism of action may be increased metabolism of both drugs.<br />
Addition or withdrawal of valproic acid during adjunctive therapy with topiramate may<br />
require a dose adjustment of topiramate and/or valproic acid.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE<br><br />
KETOCONAZOLE<br><br />
FLUCONAZOLE<br><br />
MICONAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">These drugs may increase the effect of warfarin. The mechanism is<br />
unknown. Close monitoring of the INR is recommended if these drugs must be used<br />
together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">CELECOXIB<br><br />
ROFECOXIB</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Risk of bleeding is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may inhibit the hepatic metabolism of<br />
warfarin resulting in an enhanced anticoagulant effect. Data are available for<br />
erythromycin and clarithromycin only. Close monitoring of the INR is recommended if a<br />
macrolide antimicrobial and warfarin must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Metronidazole may inhibit the metabolism of warfarin and increase its<br />
anticoagulant effect. The INR should be monitored closely.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Warfarin can increase phenytoin half-life and serum concentrations.<br />
The addition of phenytoin to warfarin therapy can increase the INR. The mechanism is not<br />
known. Serum phenytoin concentrations and INR should be monitored in patients receiving<br />
this combination.</font></td><br />
</tr><br />
<br />
<tr align="left"><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINOLONES*<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Most fluoroquinolones can inhibit the metabolism of warfarin<br />
increasing the INR. Patients on concomitant therapy should be monitored for elevations in<br />
INR. However, one study of sixteen volunteers reported a lack of interaction between<br />
warfarin and levofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine can induce hypoprothrombinemia, thus raising the INR and<br />
increasing the risk of bleeding.<br />
</td></tr></table></div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug-Drug_Interaction_RulesDrug-Drug Interaction Rules2008-02-20T20:42:56Z<p>AdamWright: </p>
<hr />
<div>These drug interactions are based on a set released by the Beth-Israel Deaconess Hospital, and are used here with permission. [http://geekdoctor.blogspot.com/2008/02/provider-order-entry.html (1)] [http://mycourses.med.harvard.edu/ec_res/nt/8AD4BE90-283F-4A6A-AADB-9F0DB529FA1E/drugdrug.doc (2)]. Several of the interactions refer to [[drug classes]], which are defined on the [[drug classes]] page.<br />
<br />
<table border="1" cellpadding="1" cellspacing="2"><br />
<tr><br />
<td><font size="2"><b>Generic Drug Name or Category</b></font></td><br />
<br />
<td><font size="2"><b>Interacts With</b></font></td><br />
<br />
<td><font size="2"><b>Severity</b></font></td><br />
<br />
<td><font size="2"><b>Text</b></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">POTASSIUM-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Diuretics and ACE inhibitors used together may cause hypotension. The<br />
combination of ACE inhibitors and potassium-sparing diuretics may cause significant<br />
hyperkalemia. This effect is particularly significant in patients with renal<br />
insufficiency.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *</font></td><br />
<br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">ACE inhibitors may decrease aldosterone causing hyperkalemia. When ACE<br />
inhibitors are coadministered with potassium-containing products, the risk of<br />
hyperkalemia is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">AZATHIOPRINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Allopurinol inhibits the metabolism of oral azathioprine, increasing<br />
serum azathioprine levels. Concomitant use can cause marked bone marrow suppression. If<br />
these drugs must be used together, azathioprine oral doses should be reduced to 25-30% of<br />
the usual dosage and the patient should be monitored closely for toxicity. Intravenous<br />
azathioprine does not appear to be affected by allopurinol.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Concurrent use of allopurinol and theophylline may result in<br />
theophylline toxicity (nausea, vomiting, palpitations, seizures). This interaction is<br />
more likely to occur with daily allopurinol doses of 600 mg or more.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Reports suggest that amiodarone may interfere with the clearance of<br />
cyclosporine. The risk of cyclosporine toxicity may increase.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may increase serum digoxin concentrations by up to 100%.<br />
Amiodarone may increase intestinal transit time, reduce renal clearance of digoxin,<br />
inhibit hepatic metabolism of digoxin, displace digoxin from protein-binding sites, and,<br />
in some cases, induce hypothyroidism. Empirical reduction or discontinuation of digoxin<br />
should be considered. Management also consists of monitoring clinical response or<br />
checking serum digoxin levels if toxicity is suspected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may inhibit hepatic metabolism of warfarin. A 30% to 50%<br />
reduction in warfarin dosage is recommended, as is frequent monitoring of<br />
INR.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some azoles, particulary Ketoconazole and Itraconazole, may inhibit<br />
the hepatic metabolism of cyclosporine. Serum cyclosporine concentrations and<br />
nephrotoxicity may increase fourfold. Cyclosporine dosage reductions of 80% have been<br />
necessary in some patients.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The use of HMG-CoA reductase inhibitors during azole therapy may<br />
increase CK, AST, ALT, and LDH serum levels.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">BETA BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of these drugs may cause severe bradycardia, cardiac<br />
arrest, or ventricular fibrillation. Use extreme caution using these drugs<br />
together.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL *</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The concomitant use of calcium channel blockers and beta-blockers can<br />
occasionally cause AV heart block and left-ventricular dysfunction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase levels of calcium channel<br />
blockers. Be careful using this combination of drugs, and monitor for<br />
toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CIMETIDINE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Cimetidine inhibits the hepatic metabolism of warfarin, and may<br />
increase its anticoagulant effect over a one to two week period. If given together, the<br />
INR should be monitored, and the lowest possible dose of cimetidine should be used.<br />
Another histamine-2 antagonist may be used with less risk of interaction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CLOPIDOGREL BISULFATE</font></td><br />
<br />
<td><font size="2">NSAIDs *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The coadministration of nonsteroidal antiinflammatory drugs (NSAIDs)<br />
and clopidogrel should be undertaken with extreme caution. The coadministration of<br />
clopidogrel with naproxen resulted in occult gastrointestinal blood loss in healthy<br />
volunteers. The mechanism may be due to additive platelet inhibition. Additionally,<br />
diclofenac, ibuprofen, naproxen, mefenamic acid, indomethacin and piroxicam are<br />
substrates for the cytochrome P450 isoenzyme 2C9 inhibited by clopidogrel. The clinical<br />
magnitude of this interaction is not known. The clinician should observe the patient for<br />
increased NSAID toxicity if these agents are co-administered with<br />
clopidogrel.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may significantly increase cyclosporine<br />
serum concentrations, possibly by inhibiting hepatic metabolism of cyclosporine,<br />
resulting in nephrotoxicity. Appropriate monitoring of cyclosporine serum concentrations<br />
during co-administration is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">FOSCARNET SODIUM</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Foscarnet and cyclosporine used together may increase the risk of<br />
nephrotoxicity and renal failure. If these agents are used concomitantly, consider close<br />
observation of renal function and discontinue foscarnet if needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with high doses of Gemfibrozil can<br />
cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with moderate to high doses of HMG CoA<br />
reductase inhibitors can cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL<br><br />
DILTIAZEM</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil and Diltiazem may inhibit the hepatic metabolism of<br />
cyclosporine causing increased trough and steady state levels, and the risk of<br />
nephrotoxicity. Cyclosporine levels should be monitored, and dosage should be adjusted as<br />
needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DAPSONE</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Saquinavir may competitively inhibit the metabolism of drugs that are<br />
substrates of the cytochrome P-450 (3A4) microsomal enzymatic pathway. Plasma levels of<br />
these drugs may be elevated. The patient should be monitored closely for toxicities and<br />
lower dosages of these drugs may be necessary</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Theoretically this interaction might occur with other macrolides.<br />
Patients should be closely monitored for evidence of digoxin toxicity if macrolide<br />
antibiotics and digoxin must be coadministered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The addition of itraconazole to patients stabilized on digoxin has<br />
resulted in two to fourfold increases in serum digoxin concentrations and digoxin<br />
toxicity. The mechanism is unknown. The onset of toxicity generally occurs within 9 to 13<br />
days after the start of itraconazole therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">QUINIDINE<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine significantly increases serum digoxin levels in more than<br />
90% of patients. The mechanism is related to reduced renal and biliary clearance, and<br />
reduced volume of digoxin distribution. Empiric reduction in digoxin dosing may be<br />
considered at the initiation of combination therapy. Modifications in dosage should be<br />
expected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">TETRACYCLINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Tetracyclines may increase serum levels of orally administered digoxin<br />
in about 10% of the population. The mechanism may be related to changes in intestinal<br />
flora that alter the absorption of digoxin. If these drugs must be used together, the<br />
patient should be closely monitored for digoxin toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil increases digoxin levels significantly in most patients.<br />
This important and possibly severe interaction is related to several complex mechanisms.<br />
Digoxin and verapamil have additive effects in slowing AV conduction. Verapamil also<br />
decreases the elimination of digoxin. If verapamil and digoxin are used together to<br />
control a supraventricular tachyarrhythmia, the dosage of each drug may have to be<br />
reduced.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">CLARITHROMYCIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Efavirenz increases the metabolism of clarithromycin. No dosage<br />
adjustment is recommended when these drugs are co-administered, but a rash occurs in 46%<br />
of patients administered clarithromycin and efavirenz concomitantly. Alternative therapy<br />
such as azithromycin might be considered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">INDINAVIR SULFATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Coadministration of efavirenz and indinavir causes a decreased<br />
indinavir level. The mechanism of this interaction is hepatic enzyme induction of CYP3A4<br />
by efavirenz. The dosage of indinavir should be increased from 800 mg every 8 hours to<br />
1000 mg every 8 hours when these drugs are administered concomitantly.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ENOXAPARIN<br><br />
DALTEPARIN<br><br />
TINZAPARIN</font></td><br />
<br />
<td><font size="2">HEPARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Dalteparin may increase the risk of bleeding from heparin. The<br />
mechanism is additive inhibition of thrombin and factor Xa. If these agents must be used<br />
together, extreme caution is advised, and the patient should be monitored for signs of<br />
bleeding. Other low-molecular-weight heparins (LMWHs) may interact with heparin in a<br />
similar manner.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">KETOROLAC</font></td><br />
<br />
<td><font size="2">NSAIDs *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ketorolac is contraindicated in patients concurrently receiving<br />
aspirin or NSAIDs because of the cumulative risks of inducing serious NSAID-related<br />
adverse events (peptic ulcers, gastrointestinal bleeding and/or perforation).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">When lovastatin and some macrolide antibiotics (erythromycin) have<br />
been used concomitantly in severely ill patients, severe myopathy and rhabdomyolysis have<br />
resulted. The mechanism appears to be inhibition of lovastatin metabolism by the<br />
macrolide. Patients should be instructed to report symptoms of muscle pain, weakness, or<br />
tenderness. If symptoms occur, creatine kinase should be measured. If creatine kinase is<br />
elevated, the drugs should be discontinued. A similar reaction may occur with other<br />
HMG-CoA reductase inhibitors.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">FENTANYL</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase fentanyl plasma levels. Patients<br />
should be closely observed for toxicity if these drugs are used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Gemfibrozil and lovastatin used together can cause severe myopathy and<br />
rhabdomyolysis. Combined use of gemfibrozil or clofibrate with other HMG-CoA reductase<br />
inhibitors may increase the risk of this side effect as well. If this combination must be<br />
used, the patient should be instructed to report symptoms of muscular pain, weakness, or<br />
tenderness. If creatine kinase is elevated, the drugs should be discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Immediate onset of excitement, sweating, rigidity, and hypertension<br />
can occur when monoamine oxidase inhibitors (MAOIs) are used concurrently with<br />
meperidine. Death has been reported. Similar effects have been reported with propoxyphene<br />
and fentanyl, but not with other analgesics. The combination of narcotic analgesics and<br />
MAOIs should be avoided if possible. An MAOI plus meperidine should not be used under any<br />
circumstances.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">COMT INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) stop the catalyst enzyme<br />
catechol-O-methyltransferase (COMT) from metabolizing levodopa to 3-O-methyldopa in the<br />
periphery, and in the brain.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SSRI ANTIDEPRESSANTS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Severe and sometimes fatal reactions involving elevations in blood<br />
pressure, hyperthermia, rigidity, and autonomic instability have occurred in patients<br />
taking SSRIs in combination with monoamine oxidase inhibitors (MAOIs). A minimum period<br />
of two weeks should separate use of these drugs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SYMPATHOMIMETIC AGENTS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sympathomimetic amines used with monoamine oxidase inhibitors may<br />
precipitate severe hypertensive reactions</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">TRICYCLIC ANTIDEPRESSANTS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants<br />
when used together may cause hyperpyretic crises, disseminated intravascular coagulation,<br />
convulsions, and death. The mechanism is unknown. Although these agents have been used<br />
together safely in many patients, some investigators recommend that tricyclic<br />
antidepressants not be used within two weeks of MAOIs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">VENLAFAXINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) used together with<br />
anti-depressants may cause severe, even fatal, reactions. The reactions reported with the<br />
newer antidepressants include hyperthermia, rigidity, myoclonus, autonomic instability,<br />
and mental status changes that range from delirium to coma. In general, MAOIs and<br />
venlafaxine or other SSRIs should be separated by 2 weeks.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NARCOTICS *<br></font></td><br />
<br />
<td><font size="2">BENZODIAZEPINES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Narcotics and benzodiazepines used together can cause excessive<br />
respiratory and CNS depression. The mechanism may be related in part to inhibition of<br />
hepatic oxidation of the benzodiazepine. Alprazolam has been most implicated in this<br />
interaction. Such interactions are more likely to occur in the benzodiazepine and<br />
narcotic "naive" patient.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NEVIRAPINE</font></td><br />
<br />
<td><font size="2">PROTEASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Because nevirapine may induce the hepatic P450 cytochrome system,<br />
reductions in plasma concentrations of protease inhibitors theoretically may occur. The<br />
manufacturer recommends that, until clinical studies provide information on dosage<br />
adjustments, protease inhibitors should not be administered concomitantly with<br />
nevirapine.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NIACIN</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Lovastatin and niacin used together may cause severe myopathy and<br />
rhabdomyolysis. Although this reaction has not been reported with concomitant use of<br />
pravastatin and niacin, patients should be instructed to report symptoms of muscle pain,<br />
weakness, or tenderness. If creatine kinase is elevated, the drugs should be<br />
discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMINOGLYCOSIDES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Aminoglycoside antibiotics may potentiate the neuromuscular blockade<br />
caused by non-depolarizing muscle relaxants. The mechanism is presynaptic acetylcholine<br />
release and reduction of postsynaptic sensitivity to acetylcholine. These combinations<br />
should be avoided if possible.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">POLYMYXIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Polymyxin B may prolong apnea and respiratory paralysis after use of<br />
neuromuscular blocking agents. The mechanism may be related to decreased intracellular<br />
potassium or decreased ionized serum calcium. Intravenous calcium administration may be<br />
helpful in reversing the paralysis.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">There may be an increased risk of CNS or respiratory depression when<br />
this combination of drugs is used.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Phenytoin may significantly reduce cyclosporine serum concentrations.<br />
The mechanism may be inhibition of cyclosporine absorption or induction of hepatic<br />
metabolism or both. This interaction may occur with ethotoin, fosphenytoin, and<br />
mephenytoin as well. Cyclosporine levels should be closely monitored during concomitant<br />
therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Dilantin can accelerate the metabolism of ritonavir thus reducing its<br />
plasma concentration. Ritonavir can raise or lower dilantin levels. Use caution if these<br />
drugs must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">POTASSIUM-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of potassium-sparing diuretics and potassium<br />
preparations may result in hyperkalemia. These agents should not be used together unless<br />
the patient has documented hypokalemia while taking either agent alone. If this<br />
combination is used, the patient should be given dietary counseling and monitored very<br />
closely for hyperkalemia.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PROCAINAMIDE</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some beta-blockers may decrease the clearance and increase the serum<br />
level of procainamide. Data are available for metoprolol and propranolol<br />
only.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone can increase quinidine concentrations inducing prolongation<br />
of the QT interval. Quinidine dose may need to be reduced by 50% if amiodarone is<br />
added.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil may increase plasma quinidine concentrations. While these<br />
drugs can be given together safely, significant adverse side effects can occur,<br />
especially in patients with hypertrophic or dilated cardiomyopathies and in patients on<br />
higher doses of either drug. If these drugs must be given together, lower doses of<br />
quinidine are needed to achieve a given plasma concentration and clinical response.<br />
Clinical and electrocardiographic monitoring for quinidine toxicity (such as hypotension,<br />
arrhythmias, and AV block) is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may interfere with the metabolism of meperidine. Large<br />
increases in serum meperidine concentrations may result. The concomitant use of these<br />
agents is contraindicated by the manufacturer and should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir capsules and ritonavir oral solution contain alcohol, which<br />
may cause a reaction when this drug is used with disulfiram or metronidazole.<br />
Simultaneous use should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The plasma concentration of saquinavir mesylate (Invirase) is<br />
increased markedly (29-fold) by ritonavir. The safety of their concurrent use has not<br />
been established. The newer form of saquinavir (Fortovase) is more bioavailable.<br />
Therefore, this interaction is less relevant for saquinavir (Fortovase).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may cause large fluctuations in the serum concentrations of<br />
warfarin. If ritonavir and warfarin must be used together, frequent monitoring of the INR<br />
is strongly recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFADIAZINE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some sulfonamides inhibit the hepatic metabolism of phenytoin. Serum<br />
phenytoin levels and risk of toxicity may be increased. Data are available for<br />
sulfadiazine and sulfamethizole. Management consists of monitoring the patient for signs<br />
and symptoms of phenytoin toxicity, checking serum levels, and decreasing phenytoin<br />
dosage as necessary.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFAMETHOXAZOLE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sulfonamides increase the level of warfarin-(S) isomer by an unknown<br />
mechanism. Hypoprothrombinemic effect is enhanced. . Frequent monitoring of the INR is<br />
recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TACROLIMUS</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">In vitro and in vivo data suggest that erythromycin may inhibit the<br />
hepatic metabolism of tacrolimus. Data from two case reports suggest that concomitant use<br />
of erythromycin may result in elevated serum tacrolimus concentrations. If these drugs<br />
are used concomitantly, plasma tacrolimus concentrations should be carefully monitored,<br />
with reductions in dosage to prevent nephrotoxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">CIPROFLOXACIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ciprofloxacin can significantly reduce the clearance of theophylline<br />
by inhibition of hepatic metabolism. The interaction can result in theophylline toxicity,<br />
and may increase the risk of seizures, especially in the elderly. The patient should be<br />
monitored for theophylline toxicity and elevated serum levels while also taking<br />
ciprofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolides (erythromycin and troleandomycin) inhibit theophylline<br />
metabolism. During coadministration, serum theophylline levels and risk of theophylline<br />
toxicity are increased. Conversely, theophylline increases the renal clearance of<br />
erythromycin and decreases erythromycin concentrations. Monitoring of theophylline levels<br />
and efficacy is recommended when erythromycin is added to or discontinued from the<br />
patient's regimen. [Dirithromycin [?on formulary]appears to increase the plasma clearance<br />
of theophylline, and plasma theophylline concentrations can be decreased by approximately<br />
26%. The dirithromycin-theophylline interaction is unlikely to be clinically significant<br />
enough to modify treatment and outcome.] The effects of azithromycin and clarithromycin<br />
on the pharmacokinetic disposition of theophylline are not known. Azithromycin, however,<br />
does not appear to interfere with theophylline levels and may be the macrolide of choice<br />
for patients on theophylline therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with phenytoin may cause a 25% increase in<br />
phenytoin plasma concentration, particularly in patients receiving phenytoin twice a day.<br />
Additionally, the concentration of topiramate decreased by 48%. Addition or withdrawal of<br />
hydantoins during therapy with topiramate may require a dose adjustment of topiramate<br />
and/or the hydantoin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">VALPROATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with valproic acid may lead to an 11% decrease<br />
in valproic acid plasma concentration. Additionally, the concentration of topiramate<br />
decreased by 14%. The mechanism of action may be increased metabolism of both drugs.<br />
Addition or withdrawal of valproic acid during adjunctive therapy with topiramate may<br />
require a dose adjustment of topiramate and/or valproic acid.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE<br><br />
KETOCONAZOLE<br><br />
FLUCONAZOLE<br><br />
MICONAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">These drugs may increase the effect of warfarin. The mechanism is<br />
unknown. Close monitoring of the INR is recommended if these drugs must be used<br />
together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">CELECOXIB<br><br />
ROFECOXIB</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Risk of bleeding is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may inhibit the hepatic metabolism of<br />
warfarin resulting in an enhanced anticoagulant effect. Data are available for<br />
erythromycin and clarithromycin only. Close monitoring of the INR is recommended if a<br />
macrolide antimicrobial and warfarin must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Metronidazole may inhibit the metabolism of warfarin and increase its<br />
anticoagulant effect. The INR should be monitored closely.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Warfarin can increase phenytoin half-life and serum concentrations.<br />
The addition of phenytoin to warfarin therapy can increase the INR. The mechanism is not<br />
known. Serum phenytoin concentrations and INR should be monitored in patients receiving<br />
this combination.</font></td><br />
</tr><br />
<br />
<tr align="left"><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINOLONES*<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Most fluoroquinolones can inhibit the metabolism of warfarin<br />
increasing the INR. Patients on concomitant therapy should be monitored for elevations in<br />
INR. However, one study of sixteen volunteers reported a lack of interaction between<br />
warfarin and levofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine can induce hypoprothrombinemia, thus raising the INR and<br />
increasing the risk of bleeding.<br />
</td></tr></table></div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug-Drug_Interaction_RulesDrug-Drug Interaction Rules2008-02-20T20:40:22Z<p>AdamWright: </p>
<hr />
<div>These drug interactions are based on a set released by the Beth-Israel Deaconess Hospital, and are used here with permission. [http://geekdoctor.blogspot.com/2008/02/provider-order-entry.html (1)] [http://mycourses.med.harvard.edu/ec_res/nt/8AD4BE90-283F-4A6A-AADB-9F0DB529FA1E/drugdrug.doc (2)]. Several of the interactions refer to [[drug classes]], which are defined on the [[drug classes]] page.<br />
<br />
<table border="1" cellpadding="1" cellspacing="2"><br />
<tr><br />
<td><font size="2"><b>Generic Drug Name or Category</b></font></td><br />
<br />
<td><font size="2"><b>Interacts With</b></font></td><br />
<br />
<td><font size="2"><b>Severity</b></font></td><br />
<br />
<td><font size="2"><b>Text</b></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">POTASSIUM-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Diuretics and ACE inhibitors used together may cause hypotension. The<br />
combination of ACE inhibitors and potassium-sparing diuretics may cause significant<br />
hyperkalemia. This effect is particularly significant in patients with renal<br />
insufficiency.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *</font></td><br />
<br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">ACE inhibitors may decrease aldosterone causing hyperkalemia. When ACE<br />
inhibitors are coadministered with potassium-containing products, the risk of<br />
hyperkalemia is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">AZATHIOPRINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Allopurinol inhibits the metabolism of oral azathioprine, increasing<br />
serum azathioprine levels. Concomitant use can cause marked bone marrow suppression. If<br />
these drugs must be used together, azathioprine oral doses should be reduced to 25-30% of<br />
the usual dosage and the patient should be monitored closely for toxicity. Intravenous<br />
azathioprine does not appear to be affected by allopurinol.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Concurrent use of allopurinol and theophylline may result in<br />
theophylline toxicity (nausea, vomiting, palpitations, seizures). This interaction is<br />
more likely to occur with daily allopurinol doses of 600 mg or more.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Reports suggest that amiodarone may interfere with the clearance of<br />
cyclosporine. The risk of cyclosporine toxicity may increase.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may increase serum digoxin concentrations by up to 100%.<br />
Amiodarone may increase intestinal transit time, reduce renal clearance of digoxin,<br />
inhibit hepatic metabolism of digoxin, displace digoxin from protein-binding sites, and,<br />
in some cases, induce hypothyroidism. Empirical reduction or discontinuation of digoxin<br />
should be considered. Management also consists of monitoring clinical response or<br />
checking serum digoxin levels if toxicity is suspected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may inhibit hepatic metabolism of warfarin. A 30% to 50%<br />
reduction in warfarin dosage is recommended, as is frequent monitoring of<br />
INR.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some azoles, particulary Ketoconazole and Itraconazole, may inhibit<br />
the hepatic metabolism of cyclosporine. Serum cyclosporine concentrations and<br />
nephrotoxicity may increase fourfold. Cyclosporine dosage reductions of 80% have been<br />
necessary in some patients.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The use of HMG-CoA reductase inhibitors during azole therapy may<br />
increase CK, AST, ALT, and LDH serum levels.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">BETA BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of these drugs may cause severe bradycardia, cardiac<br />
arrest, or ventricular fibrillation. Use extreme caution using these drugs<br />
together.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL *</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The concomitant use of calcium channel blockers and beta-blockers can<br />
occasionally cause AV heart block and left-ventricular dysfunction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase levels of calcium channel<br />
blockers. Be careful using this combination of drugs, and monitor for<br />
toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CIMETIDINE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Cimetidine inhibits the hepatic metabolism of warfarin, and may<br />
increase its anticoagulant effect over a one to two week period. If given together, the<br />
INR should be monitored, and the lowest possible dose of cimetidine should be used.<br />
Another histamine-2 antagonist may be used with less risk of interaction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CLOPIDOGREL BISULFATE</font></td><br />
<br />
<td><font size="2">NSAIDs *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The coadministration of nonsteroidal antiinflammatory drugs (NSAIDs)<br />
and clopidogrel should be undertaken with extreme caution. The coadministration of<br />
clopidogrel with naproxen resulted in occult gastrointestinal blood loss in healthy<br />
volunteers. The mechanism may be due to additive platelet inhibition. Additionally,<br />
diclofenac, ibuprofen, naproxen, mefenamic acid, indomethacin and piroxicam are<br />
substrates for the cytochrome P450 isoenzyme 2C9 inhibited by clopidogrel. The clinical<br />
magnitude of this interaction is not known. The clinician should observe the patient for<br />
increased NSAID toxicity if these agents are co-administered with<br />
clopidogrel.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may significantly increase cyclosporine<br />
serum concentrations, possibly by inhibiting hepatic metabolism of cyclosporine,<br />
resulting in nephrotoxicity. Appropriate monitoring of cyclosporine serum concentrations<br />
during co-administration is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">FOSCARNET SODIUM</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Foscarnet and cyclosporine used together may increase the risk of<br />
nephrotoxicity and renal failure. If these agents are used concomitantly, consider close<br />
observation of renal function and discontinue foscarnet if needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with high doses of Gemfibrozil can<br />
cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with moderate to high doses of HMG CoA<br />
reductase inhibitors can cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL<br><br />
DILTIAZEM</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil and Diltiazem may inhibit the hepatic metabolism of<br />
cyclosporine causing increased trough and steady state levels, and the risk of<br />
nephrotoxicity. Cyclosporine levels should be monitored, and dosage should be adjusted as<br />
needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DAPSONE</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Saquinavir may competitively inhibit the metabolism of drugs that are<br />
substrates of the cytochrome P-450 (3A4) microsomal enzymatic pathway. Plasma levels of<br />
these drugs may be elevated. The patient should be monitored closely for toxicities and<br />
lower dosages of these drugs may be necessary</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Theoretically this interaction might occur with other macrolides.<br />
Patients should be closely monitored for evidence of digoxin toxicity if macrolide<br />
antibiotics and digoxin must be coadministered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The addition of itraconazole to patients stabilized on digoxin has<br />
resulted in two to fourfold increases in serum digoxin concentrations and digoxin<br />
toxicity. The mechanism is unknown. The onset of toxicity generally occurs within 9 to 13<br />
days after the start of itraconazole therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">QUINIDINE<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine significantly increases serum digoxin levels in more than<br />
90% of patients. The mechanism is related to reduced renal and biliary clearance, and<br />
reduced volume of digoxin distribution. Empiric reduction in digoxin dosing may be<br />
considered at the initiation of combination therapy. Modifications in dosage should be<br />
expected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">TETRACYCLINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Tetracyclines may increase serum levels of orally administered digoxin<br />
in about 10% of the population. The mechanism may be related to changes in intestinal<br />
flora that alter the absorption of digoxin. If these drugs must be used together, the<br />
patient should be closely monitored for digoxin toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil increases digoxin levels significantly in most patients.<br />
This important and possibly severe interaction is related to several complex mechanisms.<br />
Digoxin and verapamil have additive effects in slowing AV conduction. Verapamil also<br />
decreases the elimination of digoxin. If verapamil and digoxin are used together to<br />
control a supraventricular tachyarrhythmia, the dosage of each drug may have to be<br />
reduced.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">CLARITHROMYCIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Efavirenz increases the metabolism of clarithromycin. No dosage<br />
adjustment is recommended when these drugs are co-administered, but a rash occurs in 46%<br />
of patients administered clarithromycin and efavirenz concomitantly. Alternative therapy<br />
such as azithromycin might be considered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">INDINAVIR SULFATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Coadministration of efavirenz and indinavir causes a decreased<br />
indinavir level. The mechanism of this interaction is hepatic enzyme induction of CYP3A4<br />
by efavirenz. The dosage of indinavir should be increased from 800 mg every 8 hours to<br />
1000 mg every 8 hours when these drugs are administered concomitantly.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ENOXAPARIN<br><br />
DALTEPARIN<br><br />
TINZAPARIN</font></td><br />
<br />
<td><font size="2">HEPARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Dalteparin may increase the risk of bleeding from heparin. The<br />
mechanism is additive inhibition of thrombin and factor Xa. If these agents must be used<br />
together, extreme caution is advised, and the patient should be monitored for signs of<br />
bleeding. Other low-molecular-weight heparins (LMWHs) may interact with heparin in a<br />
similar manner.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">KETOROLAC</font></td><br />
<br />
<td><font size="2">NSAIDs *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ketorolac is contraindicated in patients concurrently receiving<br />
aspirin or NSAIDs because of the cumulative risks of inducing serious NSAID-related<br />
adverse events (peptic ulcers, gastrointestinal bleeding and/or perforation).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">When lovastatin and some macrolide antibiotics (erythromycin) have<br />
been used concomitantly in severely ill patients, severe myopathy and rhabdomyolysis have<br />
resulted. The mechanism appears to be inhibition of lovastatin metabolism by the<br />
macrolide. Patients should be instructed to report symptoms of muscle pain, weakness, or<br />
tenderness. If symptoms occur, creatine kinase should be measured. If creatine kinase is<br />
elevated, the drugs should be discontinued. A similar reaction may occur with other<br />
HMG-CoA reductase inhibitors.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">FENTANYL</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase fentanyl plasma levels. Patients<br />
should be closely observed for toxicity if these drugs are used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Gemfibrozil and lovastatin used together can cause severe myopathy and<br />
rhabdomyolysis. Combined use of gemfibrozil or clofibrate with other HMG-CoA reductase<br />
inhibitors may increase the risk of this side effect as well. If this combination must be<br />
used, the patient should be instructed to report symptoms of muscular pain, weakness, or<br />
tenderness. If creatine kinase is elevated, the drugs should be discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Immediate onset of excitement, sweating, rigidity, and hypertension<br />
can occur when monoamine oxidase inhibitors (MAOIs) are used concurrently with<br />
meperidine. Death has been reported. Similar effects have been reported with propoxyphene<br />
and fentanyl, but not with other analgesics. The combination of narcotic analgesics and<br />
MAOIs should be avoided if possible. An MAOI plus meperidine should not be used under any<br />
circumstances.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">COMT INHIBITORS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) stop the catalyst enzyme<br />
catechol-O-methyltransferase (COMT) from metabolizing levodopa to 3-O-methyldopa in the<br />
periphery, and in the brain.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SSRI ANTIDEPRESSANTS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Severe and sometimes fatal reactions involving elevations in blood<br />
pressure, hyperthermia, rigidity, and autonomic instability have occurred in patients<br />
taking SSRIs in combination with monoamine oxidase inhibitors (MAOIs). A minimum period<br />
of two weeks should separate use of these drugs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SYMPATHOMIMETIC AGENTS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sympathomimetic amines used with monoamine oxidase inhibitors may<br />
precipitate severe hypertensive reactions</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">TRICYCLIC ANTIDEPRESSANTS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants<br />
when used together may cause hyperpyretic crises, disseminated intravascular coagulation,<br />
convulsions, and death. The mechanism is unknown. Although these agents have been used<br />
together safely in many patients, some investigators recommend that tricyclic<br />
antidepressants not be used within two weeks of MAOIs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">VENLAFAXINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) used together with<br />
anti-depressants may cause severe, even fatal, reactions. The reactions reported with the<br />
newer antidepressants include hyperthermia, rigidity, myoclonus, autonomic instability,<br />
and mental status changes that range from delirium to coma. In general, MAOIs and<br />
venlafaxine or other SSRIs should be separated by 2 weeks.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NARCOTICS *<br></font></td><br />
<br />
<td><font size="2">BENZODIAZEPINES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Narcotics and benzodiazepines used together can cause excessive<br />
respiratory and CNS depression. The mechanism may be related in part to inhibition of<br />
hepatic oxidation of the benzodiazepine. Alprazolam has been most implicated in this<br />
interaction. Such interactions are more likely to occur in the benzodiazepine and<br />
narcotic "naive" patient.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NEVIRAPINE</font></td><br />
<br />
<td><font size="2">PROTEASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Because nevirapine may induce the hepatic P450 cytochrome system,<br />
reductions in plasma concentrations of protease inhibitors theoretically may occur. The<br />
manufacturer recommends that, until clinical studies provide information on dosage<br />
adjustments, protease inhibitors should not be administered concomitantly with<br />
nevirapine.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NIACIN</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Lovastatin and niacin used together may cause severe myopathy and<br />
rhabdomyolysis. Although this reaction has not been reported with concomitant use of<br />
pravastatin and niacin, patients should be instructed to report symptoms of muscle pain,<br />
weakness, or tenderness. If creatine kinase is elevated, the drugs should be<br />
discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMINOGLYCOSIDES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Aminoglycoside antibiotics may potentiate the neuromuscular blockade<br />
caused by non-depolarizing muscle relaxants. The mechanism is presynaptic acetylcholine<br />
release and reduction of postsynaptic sensitivity to acetylcholine. These combinations<br />
should be avoided if possible.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">POLYMYXIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Polymyxin B may prolong apnea and respiratory paralysis after use of<br />
neuromuscular blocking agents. The mechanism may be related to decreased intracellular<br />
potassium or decreased ionized serum calcium. Intravenous calcium administration may be<br />
helpful in reversing the paralysis.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">There may be an increased risk of CNS or respiratory depression when<br />
this combination of drugs is used.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Phenytoin may significantly reduce cyclosporine serum concentrations.<br />
The mechanism may be inhibition of cyclosporine absorption or induction of hepatic<br />
metabolism or both. This interaction may occur with ethotoin, fosphenytoin, and<br />
mephenytoin as well. Cyclosporine levels should be closely monitored during concomitant<br />
therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Dilantin can accelerate the metabolism of ritonavir thus reducing its<br />
plasma concentration. Ritonavir can raise or lower dilantin levels. Use caution if these<br />
drugs must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">POTASSIUM-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of potassium-sparing diuretics and potassium<br />
preparations may result in hyperkalemia. These agents should not be used together unless<br />
the patient has documented hypokalemia while taking either agent alone. If this<br />
combination is used, the patient should be given dietary counseling and monitored very<br />
closely for hyperkalemia.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PROCAINAMIDE</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some beta-blockers may decrease the clearance and increase the serum<br />
level of procainamide. Data are available for metoprolol and propranolol<br />
only.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone can increase quinidine concentrations inducing prolongation<br />
of the QT interval. Quinidine dose may need to be reduced by 50% if amiodarone is<br />
added.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil may increase plasma quinidine concentrations. While these<br />
drugs can be given together safely, significant adverse side effects can occur,<br />
especially in patients with hypertrophic or dilated cardiomyopathies and in patients on<br />
higher doses of either drug. If these drugs must be given together, lower doses of<br />
quinidine are needed to achieve a given plasma concentration and clinical response.<br />
Clinical and electrocardiographic monitoring for quinidine toxicity (such as hypotension,<br />
arrhythmias, and AV block) is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may interfere with the metabolism of meperidine. Large<br />
increases in serum meperidine concentrations may result. The concomitant use of these<br />
agents is contraindicated by the manufacturer and should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir capsules and ritonavir oral solution contain alcohol, which<br />
may cause a reaction when this drug is used with disulfiram or metronidazole.<br />
Simultaneous use should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The plasma concentration of saquinavir mesylate (Invirase) is<br />
increased markedly (29-fold) by ritonavir. The safety of their concurrent use has not<br />
been established. The newer form of saquinavir (Fortovase) is more bioavailable.<br />
Therefore, this interaction is less relevant for saquinavir (Fortovase).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may cause large fluctuations in the serum concentrations of<br />
warfarin. If ritonavir and warfarin must be used together, frequent monitoring of the INR<br />
is strongly recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFADIAZINE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some sulfonamides inhibit the hepatic metabolism of phenytoin. Serum<br />
phenytoin levels and risk of toxicity may be increased. Data are available for<br />
sulfadiazine and sulfamethizole. Management consists of monitoring the patient for signs<br />
and symptoms of phenytoin toxicity, checking serum levels, and decreasing phenytoin<br />
dosage as necessary.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFAMETHOXAZOLE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sulfonamides increase the level of warfarin-(S) isomer by an unknown<br />
mechanism. Hypoprothrombinemic effect is enhanced. . Frequent monitoring of the INR is<br />
recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TACROLIMUS</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">In vitro and in vivo data suggest that erythromycin may inhibit the<br />
hepatic metabolism of tacrolimus. Data from two case reports suggest that concomitant use<br />
of erythromycin may result in elevated serum tacrolimus concentrations. If these drugs<br />
are used concomitantly, plasma tacrolimus concentrations should be carefully monitored,<br />
with reductions in dosage to prevent nephrotoxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">CIPROFLOXACIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ciprofloxacin can significantly reduce the clearance of theophylline<br />
by inhibition of hepatic metabolism. The interaction can result in theophylline toxicity,<br />
and may increase the risk of seizures, especially in the elderly. The patient should be<br />
monitored for theophylline toxicity and elevated serum levels while also taking<br />
ciprofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolides (erythromycin and troleandomycin) inhibit theophylline<br />
metabolism. During coadministration, serum theophylline levels and risk of theophylline<br />
toxicity are increased. Conversely, theophylline increases the renal clearance of<br />
erythromycin and decreases erythromycin concentrations. Monitoring of theophylline levels<br />
and efficacy is recommended when erythromycin is added to or discontinued from the<br />
patient's regimen. [Dirithromycin [?on formulary]appears to increase the plasma clearance<br />
of theophylline, and plasma theophylline concentrations can be decreased by approximately<br />
26%. The dirithromycin-theophylline interaction is unlikely to be clinically significant<br />
enough to modify treatment and outcome.] The effects of azithromycin and clarithromycin<br />
on the pharmacokinetic disposition of theophylline are not known. Azithromycin, however,<br />
does not appear to interfere with theophylline levels and may be the macrolide of choice<br />
for patients on theophylline therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with phenytoin may cause a 25% increase in<br />
phenytoin plasma concentration, particularly in patients receiving phenytoin twice a day.<br />
Additionally, the concentration of topiramate decreased by 48%. Addition or withdrawal of<br />
hydantoins during therapy with topiramate may require a dose adjustment of topiramate<br />
and/or the hydantoin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">VALPROATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with valproic acid may lead to an 11% decrease<br />
in valproic acid plasma concentration. Additionally, the concentration of topiramate<br />
decreased by 14%. The mechanism of action may be increased metabolism of both drugs.<br />
Addition or withdrawal of valproic acid during adjunctive therapy with topiramate may<br />
require a dose adjustment of topiramate and/or valproic acid.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE<br><br />
KETOCONAZOLE<br><br />
FLUCONAZOLE<br><br />
MICONAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">These drugs may increase the effect of warfarin. The mechanism is<br />
unknown. Close monitoring of the INR is recommended if these drugs must be used<br />
together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">CELECOXIB<br><br />
ROFECOXIB</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Risk of bleeding is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may inhibit the hepatic metabolism of<br />
warfarin resulting in an enhanced anticoagulant effect. Data are available for<br />
erythromycin and clarithromycin only. Close monitoring of the INR is recommended if a<br />
macrolide antimicrobial and warfarin must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Metronidazole may inhibit the metabolism of warfarin and increase its<br />
anticoagulant effect. The INR should be monitored closely.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Warfarin can increase phenytoin half-life and serum concentrations.<br />
The addition of phenytoin to warfarin therapy can increase the INR. The mechanism is not<br />
known. Serum phenytoin concentrations and INR should be monitored in patients receiving<br />
this combination.</font></td><br />
</tr><br />
<br />
<tr align="left"><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINOLONES*<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Most fluoroquinolones can inhibit the metabolism of warfarin<br />
increasing the INR. Patients on concomitant therapy should be monitored for elevations in<br />
INR. However, one study of sixteen volunteers reported a lack of interaction between<br />
warfarin and levofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine can induce hypoprothrombinemia, thus raising the INR and<br />
increasing the risk of bleeding.<br />
</td></tr></table></div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug_classesDrug classes2008-02-20T20:39:41Z<p>AdamWright: </p>
<hr />
<div>'''ACE INHIBITORS'''<br />
* BENAZEPRIL<br />
* CAPTOPRIL<br />
* ENALAPRIL MALEATE<br />
* ENALAPRILAT<br />
* LISINOPRIL<br />
* MOEXIPRIL<br />
* QUINAPRIL<br />
* RAMIPRIL<br />
* TRANDOLAPRIL<br />
<br />
<br />
'''AMINOGLYCOSIDES'''<br />
* AMIKACIN<br />
* GENTAMICIN<br />
* KANAMYCIN<br />
* NEOMYCIN<br />
* NETILMICIN<br />
* PAROMOMYCIN<br />
* STREPTOMYCIN<br />
* TOBRAMYCIN<br />
<br />
<br />
'''AZOLE ANTIFUNGALS'''<br />
* CLOTRIMAZOLE<br />
* FLUCONAZOLE<br />
* ITRACONAZOLE<br />
* KETOCONAZOLE<br />
* MICONAZOLE<br />
<br />
<br />
'''BENZODIAZEPINES'''<br />
* ALPRAZOLAM<br />
* CHLORDIAZEPOXIDE<br />
* CLONAZEPAM<br />
* CLORAZEPATE DIPOTASSIUM<br />
* DIAZEPAM<br />
* FLURAZEPAM<br />
* LORAZEPAM<br />
* MIDAZOLAM<br />
* OXAZEPAM<br />
* TEMAZEPAM<br />
* TRIAZOLAM<br />
<br />
<br />
'''BETA BLOCKERS'''<br />
* ACEBUTOLOL<br />
* ATENOLOL<br />
* BETAXOLOL<br />
* BISOPROLOL FUMARATE<br />
* CARVEDILOL<br />
* ESMOLOL<br />
* LABETALOL<br />
* METOPROLOL<br />
* NADOLOL<br />
* PINDOLOL<br />
* PROPRANOLOL<br />
* SOTALOL<br />
* TIMOLOL<br />
<br />
<br />
'''CALCIUM CHANNEL BLOCKERS'''<br />
* AMLODIPINE BESYLATE<br />
* DILTIAZEM<br />
* FELODIPINE<br />
* ISRADIPINE<br />
* NICARDIPINE<br />
* NIFEDIPINE<br />
* NISOLDIPINE<br />
* VERAPAMIL<br />
<br />
<br />
'''COMT INHIBITORS'''<br />
* ENTACAPONE<br />
* LEVODOPA<br />
* TOLCAPONE<br />
<br />
<br />
'''HMG COA REDUCTASE INHIBITORS'''<br />
* ATORVASTATIN<br />
* CERIVASTATIN<br />
* FLUVASTATIN<br />
* LOVASTATIN<br />
* PRAVASTATIN<br />
* SIMVASTATIN<br />
<br />
<br />
'''MACROLIDES'''<br />
* AZITHROMYCIN<br />
* CLARITHROMYCIN<br />
* DIRITHROMYCIN<br />
* ERYHTROMYCIN BASE<br />
* ERYTHROMYCIN ESTOLATE<br />
* ERYTHROMYCIN ETHYLSUCCINATE<br />
* ERYTHROMYCIN GLUCEPTATE<br />
* ERYTHROMYCIN LACTOBIONATE<br />
* ERYTHROMYCIN STEARATE<br />
* TROLEANDOMYCIN<br />
<br />
<br />
'''MAO INHIBITORS'''<br />
* ISOCARBOXAZID<br />
* PHENELZINE<br />
* SELEGELINE<br />
* TRANYLCYPROMINE<br />
<br />
<br />
'''NARCOTICS'''<br />
* CODEINE<br />
* FENTANYL<br />
* HYDROMORPHONE<br />
* MEPERIDINE<br />
* METHADONE<br />
* MORPHINE<br />
* OXYCODONE<br />
* OXYMORPHONE<br />
* PROPOXYPHENE<br />
<br />
<br />
'''NM BLOCKERS'''<br />
* ATRACURIUM BESYLATE<br />
* CISATRACURIUM BESYLATE<br />
* DOXACURIUM CHLORIDE<br />
* MIVACURIUM CHLORIDE<br />
* PANCURONIUM BROMIDE<br />
* PIPECURONIUM BROMIDE<br />
* RAPACURONIUM BROMIDE<br />
* ROCURONIUM BROMIDE<br />
* SUCCINYLCHOLINE CHLORIDE<br />
* TUBOCURARINE CHLORIDE<br />
* VECURONIUM BROMIDE<br />
<br />
<br />
'''NSAIDs'''<br />
* IBUPROFEN<br />
* INDOMETHACIN<br />
* KETOROLAC<br />
* TROMETHAMINE<br />
* NAPROXEN<br />
* PIROXICAM<br />
<br />
<br />
'''POTASSIUM'''<br />
* POTASSIUM ACETATE<br />
* POTASSIUM BICARBONATE/CIT AC<br />
* POTASSIUM CHLORIDE<br />
* POTASSIUM IODIDE<br />
* POTASSIUM PHOS,M-BASIC-D-BASIC<br />
<br />
<br />
'''POTASSIUM SPARING DIURETICS'''<br />
* AMILORIDE<br />
* SPIRONOLACTONE<br />
* TRIAMTERENE<br />
<br />
<br />
'''PROTEASE INHIBITORS'''<br />
* AMPRENAVIR<br />
* INDINAVIR<br />
* MIGLITOL<br />
* RITONAVIR<br />
* SAQUINAVIR<br />
<br />
<br />
'''QUINOLONES'''<br />
* CIPROFLOXACIN<br />
* ENOXACIN<br />
* GREPAFLOXACIN<br />
* LEVOFLOXACIN<br />
* LOMEFLOXACIN<br />
* NORFLOXACIN<br />
* OFLOXACIN<br />
* SPARFLOXACIN<br />
* TROVAFLOXACIN MESYLATE<br />
<br />
<br />
'''TRICYCLIC ANTIDEPRESSANTS'''<br />
* AMITRIPTYLINE<br />
* AMOXAPINE<br />
* CLOMIPRAMINE<br />
* DESIPRAMINE<br />
* DOXEPIN<br />
* IMIPRAMINE<br />
* NORTRIPTYLINE<br />
* PROTRIPTYLINE<br />
* TRIMIPRAMINE MALEATE<br />
<br />
<br />
'''SSRI ANTIDEPRESSANTS'''<br />
* CITALOPRAM<br />
* FLUOXETINE<br />
* FLUVAOXAMINE MALEATE<br />
* PAROXETINE<br />
* SERTRALINE<br />
<br />
<br />
'''SYMPATHOMIMETIC AGENTS'''<br />
* DOBUTAMINE<br />
* DOPAMINE<br />
* EPHEDRINE<br />
* EPINEPHRINE<br />
* ISOPROTERENOL<br />
* MIDODRINE<br />
* NOREPINEPHRINE<br />
* PHENYLEPHRINE<br />
* PSEUDOEPHEDRINE<br />
* TERBUTALINE</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug_classesDrug classes2008-02-20T20:39:19Z<p>AdamWright: </p>
<hr />
<div>''''ACE INHIBITORS''''<br />
* BENAZEPRIL<br />
* CAPTOPRIL<br />
* ENALAPRIL MALEATE<br />
* ENALAPRILAT<br />
* LISINOPRIL<br />
* MOEXIPRIL<br />
* QUINAPRIL<br />
* RAMIPRIL<br />
* TRANDOLAPRIL<br />
<br />
<br />
''''AMINOGLYCOSIDES''''<br />
* AMIKACIN<br />
* GENTAMICIN<br />
* KANAMYCIN<br />
* NEOMYCIN<br />
* NETILMICIN<br />
* PAROMOMYCIN<br />
* STREPTOMYCIN<br />
* TOBRAMYCIN<br />
<br />
<br />
'''AZOLE ANTIFUNGALS'''<br />
* CLOTRIMAZOLE<br />
* FLUCONAZOLE<br />
* ITRACONAZOLE<br />
* KETOCONAZOLE<br />
* MICONAZOLE<br />
<br />
<br />
''''BENZODIAZEPINES''''<br />
* ALPRAZOLAM<br />
* CHLORDIAZEPOXIDE<br />
* CLONAZEPAM<br />
* CLORAZEPATE DIPOTASSIUM<br />
* DIAZEPAM<br />
* FLURAZEPAM<br />
* LORAZEPAM<br />
* MIDAZOLAM<br />
* OXAZEPAM<br />
* TEMAZEPAM<br />
* TRIAZOLAM<br />
<br />
<br />
''''BETA BLOCKERS''''<br />
* ACEBUTOLOL<br />
* ATENOLOL<br />
* BETAXOLOL<br />
* BISOPROLOL FUMARATE<br />
* CARVEDILOL<br />
* ESMOLOL<br />
* LABETALOL<br />
* METOPROLOL<br />
* NADOLOL<br />
* PINDOLOL<br />
* PROPRANOLOL<br />
* SOTALOL<br />
* TIMOLOL<br />
<br />
<br />
''''CALCIUM CHANNEL BLOCKERS''''<br />
* AMLODIPINE BESYLATE<br />
* DILTIAZEM<br />
* FELODIPINE<br />
* ISRADIPINE<br />
* NICARDIPINE<br />
* NIFEDIPINE<br />
* NISOLDIPINE<br />
* VERAPAMIL<br />
<br />
<br />
''''COMT INHIBITORS''''<br />
* ENTACAPONE<br />
* LEVODOPA<br />
* TOLCAPONE<br />
<br />
<br />
''''HMG COA REDUCTASE INHIBITORS''''<br />
* ATORVASTATIN<br />
* CERIVASTATIN<br />
* FLUVASTATIN<br />
* LOVASTATIN<br />
* PRAVASTATIN<br />
* SIMVASTATIN<br />
<br />
<br />
''''MACROLIDES''''<br />
* AZITHROMYCIN<br />
* CLARITHROMYCIN<br />
* DIRITHROMYCIN<br />
* ERYHTROMYCIN BASE<br />
* ERYTHROMYCIN ESTOLATE<br />
* ERYTHROMYCIN ETHYLSUCCINATE<br />
* ERYTHROMYCIN GLUCEPTATE<br />
* ERYTHROMYCIN LACTOBIONATE<br />
* ERYTHROMYCIN STEARATE<br />
* TROLEANDOMYCIN<br />
<br />
<br />
'''MAO INHIBITORS'''<br />
* ISOCARBOXAZID<br />
* PHENELZINE<br />
* SELEGELINE<br />
* TRANYLCYPROMINE<br />
<br />
<br />
''''NARCOTICS''''<br />
* CODEINE<br />
* FENTANYL<br />
* HYDROMORPHONE<br />
* MEPERIDINE<br />
* METHADONE<br />
* MORPHINE<br />
* OXYCODONE<br />
* OXYMORPHONE<br />
* PROPOXYPHENE<br />
<br />
<br />
''''NM BLOCKERS''''<br />
* ATRACURIUM BESYLATE<br />
* CISATRACURIUM BESYLATE<br />
* DOXACURIUM CHLORIDE<br />
* MIVACURIUM CHLORIDE<br />
* PANCURONIUM BROMIDE<br />
* PIPECURONIUM BROMIDE<br />
* RAPACURONIUM BROMIDE<br />
* ROCURONIUM BROMIDE<br />
* SUCCINYLCHOLINE CHLORIDE<br />
* TUBOCURARINE CHLORIDE<br />
* VECURONIUM BROMIDE<br />
<br />
<br />
''''NSAIDs''''<br />
* IBUPROFEN<br />
* INDOMETHACIN<br />
* KETOROLAC<br />
* TROMETHAMINE<br />
* NAPROXEN<br />
* PIROXICAM<br />
<br />
<br />
''''POTASSIUM''''<br />
* POTASSIUM ACETATE<br />
* POTASSIUM BICARBONATE/CIT AC<br />
* POTASSIUM CHLORIDE<br />
* POTASSIUM IODIDE<br />
* POTASSIUM PHOS,M-BASIC-D-BASIC<br />
<br />
<br />
''''POTASSIUM SPARING DIURETICS''''<br />
* AMILORIDE<br />
* SPIRONOLACTONE<br />
* TRIAMTERENE<br />
<br />
<br />
''''PROTEASE INHIBITORS''''<br />
* AMPRENAVIR<br />
* INDINAVIR<br />
* MIGLITOL<br />
* RITONAVIR<br />
* SAQUINAVIR<br />
<br />
<br />
''''QUINOLONES''''<br />
* CIPROFLOXACIN<br />
* ENOXACIN<br />
* GREPAFLOXACIN<br />
* LEVOFLOXACIN<br />
* LOMEFLOXACIN<br />
* NORFLOXACIN<br />
* OFLOXACIN<br />
* SPARFLOXACIN<br />
* TROVAFLOXACIN MESYLATE<br />
<br />
<br />
''''TRICYCLIC ANTIDEPRESSANTS''''<br />
* AMITRIPTYLINE<br />
* AMOXAPINE<br />
* CLOMIPRAMINE<br />
* DESIPRAMINE<br />
* DOXEPIN<br />
* IMIPRAMINE<br />
* NORTRIPTYLINE<br />
* PROTRIPTYLINE<br />
* TRIMIPRAMINE MALEATE<br />
<br />
<br />
''''SSRI ANTIDEPRESSANTS''''<br />
* CITALOPRAM<br />
* FLUOXETINE<br />
* FLUVAOXAMINE MALEATE<br />
* PAROXETINE<br />
* SERTRALINE<br />
<br />
<br />
''''SYMPATHOMIMETIC AGENTS''''<br />
* DOBUTAMINE<br />
* DOPAMINE<br />
* EPHEDRINE<br />
* EPINEPHRINE<br />
* ISOPROTERENOL<br />
* MIDODRINE<br />
* NOREPINEPHRINE<br />
* PHENYLEPHRINE<br />
* PSEUDOEPHEDRINE<br />
* TERBUTALINE</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug_classesDrug classes2008-02-20T20:31:48Z<p>AdamWright: </p>
<hr />
<div>'''AZOLE ANTIFUNGALS'''<br />
* CLOTRIMAZOLE<br />
* FLUCONAZOLE<br />
* ITRACONAZOLE<br />
* KETOCONAZOLE<br />
* MICONAZOLE<br />
<br />
<br />
'''MAO INHIBITORS'''<br />
* ISOCARBOXAZID<br />
* PHENELZINE<br />
* SELEGELINE<br />
* TRANYLCYPROMINE</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug-Drug_Interaction_RulesDrug-Drug Interaction Rules2008-02-20T20:30:42Z<p>AdamWright: </p>
<hr />
<div>These drug interactions are based on a set released by the Beth-Israel Deaconess Hospital, and are used here with permission. [http://geekdoctor.blogspot.com/2008/02/provider-order-entry.html (1)] [http://mycourses.med.harvard.edu/ec_res/nt/8AD4BE90-283F-4A6A-AADB-9F0DB529FA1E/drugdrug.doc (2)]. Several of the interactions refer to [[drug classes]], which are defined on the [[drug classes]] page.<br />
<br />
<table border="1" cellpadding="1" cellspacing="2"><br />
<tr><br />
<td><font size="2"><b>Generic Drug Name or Category</b></font></td><br />
<br />
<td><font size="2"><b>Interacts With</b></font></td><br />
<br />
<td><font size="2"><b>Severity</b></font></td><br />
<br />
<td><font size="2"><b>Text</b></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">K-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Diuretics and ACE inhibitors used together may cause hypotension. The<br />
combination of ACE inhibitors and potassium-sparing diuretics may cause significant<br />
hyperkalemia. This effect is particularly significant in patients with renal<br />
insufficiency.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *</font></td><br />
<br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">ACE inhibitors may decrease aldosterone causing hyperkalemia. When ACE<br />
inhibitors are coadministered with potassium-containing products, the risk of<br />
hyperkalemia is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">AZATHIOPRINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Allopurinol inhibits the metabolism of oral azathioprine, increasing<br />
serum azathioprine levels. Concomitant use can cause marked bone marrow suppression. If<br />
these drugs must be used together, azathioprine oral doses should be reduced to 25-30% of<br />
the usual dosage and the patient should be monitored closely for toxicity. Intravenous<br />
azathioprine does not appear to be affected by allopurinol.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Concurrent use of allopurinol and theophylline may result in<br />
theophylline toxicity (nausea, vomiting, palpitations, seizures). This interaction is<br />
more likely to occur with daily allopurinol doses of 600 mg or more.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Reports suggest that amiodarone may interfere with the clearance of<br />
cyclosporine. The risk of cyclosporine toxicity may increase.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may increase serum digoxin concentrations by up to 100%.<br />
Amiodarone may increase intestinal transit time, reduce renal clearance of digoxin,<br />
inhibit hepatic metabolism of digoxin, displace digoxin from protein-binding sites, and,<br />
in some cases, induce hypothyroidism. Empirical reduction or discontinuation of digoxin<br />
should be considered. Management also consists of monitoring clinical response or<br />
checking serum digoxin levels if toxicity is suspected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may inhibit hepatic metabolism of warfarin. A 30% to 50%<br />
reduction in warfarin dosage is recommended, as is frequent monitoring of<br />
INR.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some azoles, particulary Ketoconazole and Itraconazole, may inhibit<br />
the hepatic metabolism of cyclosporine. Serum cyclosporine concentrations and<br />
nephrotoxicity may increase fourfold. Cyclosporine dosage reductions of 80% have been<br />
necessary in some patients.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The use of HMG-CoA reductase inhibitors during azole therapy may<br />
increase CK, AST, ALT, and LDH serum levels.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">BETA BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of these drugs may cause severe bradycardia, cardiac<br />
arrest, or ventricular fibrillation. Use extreme caution using these drugs<br />
together.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL *</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The concomitant use of calcium channel blockers and beta-blockers can<br />
occasionally cause AV heart block and left-ventricular dysfunction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase levels of calcium channel<br />
blockers. Be careful using this combination of drugs, and monitor for<br />
toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CIMETIDINE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Cimetidine inhibits the hepatic metabolism of warfarin, and may<br />
increase its anticoagulant effect over a one to two week period. If given together, the<br />
INR should be monitored, and the lowest possible dose of cimetidine should be used.<br />
Another histamine-2 antagonist may be used with less risk of interaction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CLOPIDOGREL BISULFATE</font></td><br />
<br />
<td><font size="2">NSAIDs *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The coadministration of nonsteroidal antiinflammatory drugs (NSAIDs)<br />
and clopidogrel should be undertaken with extreme caution. The coadministration of<br />
clopidogrel with naproxen resulted in occult gastrointestinal blood loss in healthy<br />
volunteers. The mechanism may be due to additive platelet inhibition. Additionally,<br />
diclofenac, ibuprofen, naproxen, mefenamic acid, indomethacin and piroxicam are<br />
substrates for the cytochrome P450 isoenzyme 2C9 inhibited by clopidogrel. The clinical<br />
magnitude of this interaction is not known. The clinician should observe the patient for<br />
increased NSAID toxicity if these agents are co-administered with<br />
clopidogrel.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may significantly increase cyclosporine<br />
serum concentrations, possibly by inhibiting hepatic metabolism of cyclosporine,<br />
resulting in nephrotoxicity. Appropriate monitoring of cyclosporine serum concentrations<br />
during co-administration is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">FOSCARNET SODIUM</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Foscarnet and cyclosporine used together may increase the risk of<br />
nephrotoxicity and renal failure. If these agents are used concomitantly, consider close<br />
observation of renal function and discontinue foscarnet if needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with high doses of Gemfibrozil can<br />
cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with moderate to high doses of HMG CoA<br />
reductase inhibitors can cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL<br><br />
DILTIAZEM</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil and Diltiazem may inhibit the hepatic metabolism of<br />
cyclosporine causing increased trough and steady state levels, and the risk of<br />
nephrotoxicity. Cyclosporine levels should be monitored, and dosage should be adjusted as<br />
needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DAPSONE</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Saquinavir may competitively inhibit the metabolism of drugs that are<br />
substrates of the cytochrome P-450 (3A4) microsomal enzymatic pathway. Plasma levels of<br />
these drugs may be elevated. The patient should be monitored closely for toxicities and<br />
lower dosages of these drugs may be necessary</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Theoretically this interaction might occur with other macrolides.<br />
Patients should be closely monitored for evidence of digoxin toxicity if macrolide<br />
antibiotics and digoxin must be coadministered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The addition of itraconazole to patients stabilized on digoxin has<br />
resulted in two to fourfold increases in serum digoxin concentrations and digoxin<br />
toxicity. The mechanism is unknown. The onset of toxicity generally occurs within 9 to 13<br />
days after the start of itraconazole therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">QUINIDINE<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine significantly increases serum digoxin levels in more than<br />
90% of patients. The mechanism is related to reduced renal and biliary clearance, and<br />
reduced volume of digoxin distribution. Empiric reduction in digoxin dosing may be<br />
considered at the initiation of combination therapy. Modifications in dosage should be<br />
expected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">TETRACYCLINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Tetracyclines may increase serum levels of orally administered digoxin<br />
in about 10% of the population. The mechanism may be related to changes in intestinal<br />
flora that alter the absorption of digoxin. If these drugs must be used together, the<br />
patient should be closely monitored for digoxin toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil increases digoxin levels significantly in most patients.<br />
This important and possibly severe interaction is related to several complex mechanisms.<br />
Digoxin and verapamil have additive effects in slowing AV conduction. Verapamil also<br />
decreases the elimination of digoxin. If verapamil and digoxin are used together to<br />
control a supraventricular tachyarrhythmia, the dosage of each drug may have to be<br />
reduced.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">CLARITHROMYCIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Efavirenz increases the metabolism of clarithromycin. No dosage<br />
adjustment is recommended when these drugs are co-administered, but a rash occurs in 46%<br />
of patients administered clarithromycin and efavirenz concomitantly. Alternative therapy<br />
such as azithromycin might be considered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">INDINAVIR SULFATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Coadministration of efavirenz and indinavir causes a decreased<br />
indinavir level. The mechanism of this interaction is hepatic enzyme induction of CYP3A4<br />
by efavirenz. The dosage of indinavir should be increased from 800 mg every 8 hours to<br />
1000 mg every 8 hours when these drugs are administered concomitantly.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ENOXAPARIN<br><br />
DALTEPARIN<br><br />
TINZAPARIN</font></td><br />
<br />
<td><font size="2">HEPARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Dalteparin may increase the risk of bleeding from heparin. The<br />
mechanism is additive inhibition of thrombin and factor Xa. If these agents must be used<br />
together, extreme caution is advised, and the patient should be monitored for signs of<br />
bleeding. Other low-molecular-weight heparins (LMWHs) may interact with heparin in a<br />
similar manner.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">KETOROLAC</font></td><br />
<br />
<td><font size="2">NSAIDs *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ketorolac is contraindicated in patients concurrently receiving<br />
aspirin or NSAIDs because of the cumulative risks of inducing serious NSAID-related<br />
adverse events (peptic ulcers, gastrointestinal bleeding and/or perforation).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">When lovastatin and some macrolide antibiotics (erythromycin) have<br />
been used concomitantly in severely ill patients, severe myopathy and rhabdomyolysis have<br />
resulted. The mechanism appears to be inhibition of lovastatin metabolism by the<br />
macrolide. Patients should be instructed to report symptoms of muscle pain, weakness, or<br />
tenderness. If symptoms occur, creatine kinase should be measured. If creatine kinase is<br />
elevated, the drugs should be discontinued. A similar reaction may occur with other<br />
HMG-CoA reductase inhibitors.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">FENTANYL</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase fentanyl plasma levels. Patients<br />
should be closely observed for toxicity if these drugs are used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Gemfibrozil and lovastatin used together can cause severe myopathy and<br />
rhabdomyolysis. Combined use of gemfibrozil or clofibrate with other HMG-CoA reductase<br />
inhibitors may increase the risk of this side effect as well. If this combination must be<br />
used, the patient should be instructed to report symptoms of muscular pain, weakness, or<br />
tenderness. If creatine kinase is elevated, the drugs should be discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Immediate onset of excitement, sweating, rigidity, and hypertension<br />
can occur when monoamine oxidase inhibitors (MAOIs) are used concurrently with<br />
meperidine. Death has been reported. Similar effects have been reported with propoxyphene<br />
and fentanyl, but not with other analgesics. The combination of narcotic analgesics and<br />
MAOIs should be avoided if possible. An MAOI plus meperidine should not be used under any<br />
circumstances.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">COMT INHIBITORS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) stop the catalyst enzyme<br />
catechol-O-methyltransferase (COMT) from metabolizing levodopa to 3-O-methyldopa in the<br />
periphery, and in the brain.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SSRI ANTIDEPRESSANTS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Severe and sometimes fatal reactions involving elevations in blood<br />
pressure, hyperthermia, rigidity, and autonomic instability have occurred in patients<br />
taking SSRIs in combination with monoamine oxidase inhibitors (MAOIs). A minimum period<br />
of two weeks should separate use of these drugs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SYMPATHOMIMETIC AGENTS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sympathomimetic amines used with monoamine oxidase inhibitors may<br />
precipitate severe hypertensive reactions</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">TRICYCLIC ANTIDEPRESSANTS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants<br />
when used together may cause hyperpyretic crises, disseminated intravascular coagulation,<br />
convulsions, and death. The mechanism is unknown. Although these agents have been used<br />
together safely in many patients, some investigators recommend that tricyclic<br />
antidepressants not be used within two weeks of MAOIs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">VENLAFAXINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) used together with<br />
anti-depressants may cause severe, even fatal, reactions. The reactions reported with the<br />
newer antidepressants include hyperthermia, rigidity, myoclonus, autonomic instability,<br />
and mental status changes that range from delirium to coma. In general, MAOIs and<br />
venlafaxine or other SSRIs should be separated by 2 weeks.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NARCOTICS *<br></font></td><br />
<br />
<td><font size="2">BENZODIAZEPINES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Narcotics and benzodiazepines used together can cause excessive<br />
respiratory and CNS depression. The mechanism may be related in part to inhibition of<br />
hepatic oxidation of the benzodiazepine. Alprazolam has been most implicated in this<br />
interaction. Such interactions are more likely to occur in the benzodiazepine and<br />
narcotic "naive" patient.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NEVIRAPINE</font></td><br />
<br />
<td><font size="2">PROTEASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Because nevirapine may induce the hepatic P450 cytochrome system,<br />
reductions in plasma concentrations of protease inhibitors theoretically may occur. The<br />
manufacturer recommends that, until clinical studies provide information on dosage<br />
adjustments, protease inhibitors should not be administered concomitantly with<br />
nevirapine.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NIACIN</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Lovastatin and niacin used together may cause severe myopathy and<br />
rhabdomyolysis. Although this reaction has not been reported with concomitant use of<br />
pravastatin and niacin, patients should be instructed to report symptoms of muscle pain,<br />
weakness, or tenderness. If creatine kinase is elevated, the drugs should be<br />
discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMINOGLYCOSIDES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Aminoglycoside antibiotics may potentiate the neuromuscular blockade<br />
caused by non-depolarizing muscle relaxants. The mechanism is presynaptic acetylcholine<br />
release and reduction of postsynaptic sensitivity to acetylcholine. These combinations<br />
should be avoided if possible.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">POLYMYXIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Polymyxin B may prolong apnea and respiratory paralysis after use of<br />
neuromuscular blocking agents. The mechanism may be related to decreased intracellular<br />
potassium or decreased ionized serum calcium. Intravenous calcium administration may be<br />
helpful in reversing the paralysis.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">There may be an increased risk of CNS or respiratory depression when<br />
this combination of drugs is used.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Phenytoin may significantly reduce cyclosporine serum concentrations.<br />
The mechanism may be inhibition of cyclosporine absorption or induction of hepatic<br />
metabolism or both. This interaction may occur with ethotoin, fosphenytoin, and<br />
mephenytoin as well. Cyclosporine levels should be closely monitored during concomitant<br />
therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Dilantin can accelerate the metabolism of ritonavir thus reducing its<br />
plasma concentration. Ritonavir can raise or lower dilantin levels. Use caution if these<br />
drugs must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">K-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of potassium-sparing diuretics and potassium<br />
preparations may result in hyperkalemia. These agents should not be used together unless<br />
the patient has documented hypokalemia while taking either agent alone. If this<br />
combination is used, the patient should be given dietary counseling and monitored very<br />
closely for hyperkalemia.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PROCAINAMIDE</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some beta-blockers may decrease the clearance and increase the serum<br />
level of procainamide. Data are available for metoprolol and propranolol<br />
only.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone can increase quinidine concentrations inducing prolongation<br />
of the QT interval. Quinidine dose may need to be reduced by 50% if amiodarone is<br />
added.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil may increase plasma quinidine concentrations. While these<br />
drugs can be given together safely, significant adverse side effects can occur,<br />
especially in patients with hypertrophic or dilated cardiomyopathies and in patients on<br />
higher doses of either drug. If these drugs must be given together, lower doses of<br />
quinidine are needed to achieve a given plasma concentration and clinical response.<br />
Clinical and electrocardiographic monitoring for quinidine toxicity (such as hypotension,<br />
arrhythmias, and AV block) is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may interfere with the metabolism of meperidine. Large<br />
increases in serum meperidine concentrations may result. The concomitant use of these<br />
agents is contraindicated by the manufacturer and should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir capsules and ritonavir oral solution contain alcohol, which<br />
may cause a reaction when this drug is used with disulfiram or metronidazole.<br />
Simultaneous use should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The plasma concentration of saquinavir mesylate (Invirase) is<br />
increased markedly (29-fold) by ritonavir. The safety of their concurrent use has not<br />
been established. The newer form of saquinavir (Fortovase) is more bioavailable.<br />
Therefore, this interaction is less relevant for saquinavir (Fortovase).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may cause large fluctuations in the serum concentrations of<br />
warfarin. If ritonavir and warfarin must be used together, frequent monitoring of the INR<br />
is strongly recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFADIAZINE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some sulfonamides inhibit the hepatic metabolism of phenytoin. Serum<br />
phenytoin levels and risk of toxicity may be increased. Data are available for<br />
sulfadiazine and sulfamethizole. Management consists of monitoring the patient for signs<br />
and symptoms of phenytoin toxicity, checking serum levels, and decreasing phenytoin<br />
dosage as necessary.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFAMETHOXAZOLE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sulfonamides increase the level of warfarin-(S) isomer by an unknown<br />
mechanism. Hypoprothrombinemic effect is enhanced. . Frequent monitoring of the INR is<br />
recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TACROLIMUS</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">In vitro and in vivo data suggest that erythromycin may inhibit the<br />
hepatic metabolism of tacrolimus. Data from two case reports suggest that concomitant use<br />
of erythromycin may result in elevated serum tacrolimus concentrations. If these drugs<br />
are used concomitantly, plasma tacrolimus concentrations should be carefully monitored,<br />
with reductions in dosage to prevent nephrotoxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">CIPROFLOXACIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ciprofloxacin can significantly reduce the clearance of theophylline<br />
by inhibition of hepatic metabolism. The interaction can result in theophylline toxicity,<br />
and may increase the risk of seizures, especially in the elderly. The patient should be<br />
monitored for theophylline toxicity and elevated serum levels while also taking<br />
ciprofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolides (erythromycin and troleandomycin) inhibit theophylline<br />
metabolism. During coadministration, serum theophylline levels and risk of theophylline<br />
toxicity are increased. Conversely, theophylline increases the renal clearance of<br />
erythromycin and decreases erythromycin concentrations. Monitoring of theophylline levels<br />
and efficacy is recommended when erythromycin is added to or discontinued from the<br />
patient's regimen. [Dirithromycin [?on formulary]appears to increase the plasma clearance<br />
of theophylline, and plasma theophylline concentrations can be decreased by approximately<br />
26%. The dirithromycin-theophylline interaction is unlikely to be clinically significant<br />
enough to modify treatment and outcome.] The effects of azithromycin and clarithromycin<br />
on the pharmacokinetic disposition of theophylline are not known. Azithromycin, however,<br />
does not appear to interfere with theophylline levels and may be the macrolide of choice<br />
for patients on theophylline therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with phenytoin may cause a 25% increase in<br />
phenytoin plasma concentration, particularly in patients receiving phenytoin twice a day.<br />
Additionally, the concentration of topiramate decreased by 48%. Addition or withdrawal of<br />
hydantoins during therapy with topiramate may require a dose adjustment of topiramate<br />
and/or the hydantoin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">VALPROATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with valproic acid may lead to an 11% decrease<br />
in valproic acid plasma concentration. Additionally, the concentration of topiramate<br />
decreased by 14%. The mechanism of action may be increased metabolism of both drugs.<br />
Addition or withdrawal of valproic acid during adjunctive therapy with topiramate may<br />
require a dose adjustment of topiramate and/or valproic acid.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE<br><br />
KETOCONAZOLE<br><br />
FLUCONAZOLE<br><br />
MICONAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">These drugs may increase the effect of warfarin. The mechanism is<br />
unknown. Close monitoring of the INR is recommended if these drugs must be used<br />
together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">CELECOXIB<br><br />
ROFECOXIB</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Risk of bleeding is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may inhibit the hepatic metabolism of<br />
warfarin resulting in an enhanced anticoagulant effect. Data are available for<br />
erythromycin and clarithromycin only. Close monitoring of the INR is recommended if a<br />
macrolide antimicrobial and warfarin must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Metronidazole may inhibit the metabolism of warfarin and increase its<br />
anticoagulant effect. The INR should be monitored closely.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Warfarin can increase phenytoin half-life and serum concentrations.<br />
The addition of phenytoin to warfarin therapy can increase the INR. The mechanism is not<br />
known. Serum phenytoin concentrations and INR should be monitored in patients receiving<br />
this combination.</font></td><br />
</tr><br />
<br />
<tr align="left"><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINOLONES*<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Most fluoroquinolones can inhibit the metabolism of warfarin<br />
increasing the INR. Patients on concomitant therapy should be monitored for elevations in<br />
INR. However, one study of sixteen volunteers reported a lack of interaction between<br />
warfarin and levofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine can induce hypoprothrombinemia, thus raising the INR and<br />
increasing the risk of bleeding.<br />
</td></tr></table></div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug-Drug_Interaction_RulesDrug-Drug Interaction Rules2008-02-20T20:30:27Z<p>AdamWright: </p>
<hr />
<div>These drug interactions are based on a set released by the Beth-Israel Deaconess Hospital, and are used here with permission. [http://geekdoctor.blogspot.com/2008/02/provider-order-entry.html (1)] [http://mycourses.med.harvard.edu/ec_res/nt/8AD4BE90-283F-4A6A-AADB-9F0DB529FA1E/drugdrug.doc (2)]. Several of the interactions refer to [drug classes], which are defined on the [drug classes] page.<br />
<br />
<table border="1" cellpadding="1" cellspacing="2"><br />
<tr><br />
<td><font size="2"><b>Generic Drug Name or Category</b></font></td><br />
<br />
<td><font size="2"><b>Interacts With</b></font></td><br />
<br />
<td><font size="2"><b>Severity</b></font></td><br />
<br />
<td><font size="2"><b>Text</b></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">K-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Diuretics and ACE inhibitors used together may cause hypotension. The<br />
combination of ACE inhibitors and potassium-sparing diuretics may cause significant<br />
hyperkalemia. This effect is particularly significant in patients with renal<br />
insufficiency.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *</font></td><br />
<br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">ACE inhibitors may decrease aldosterone causing hyperkalemia. When ACE<br />
inhibitors are coadministered with potassium-containing products, the risk of<br />
hyperkalemia is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">AZATHIOPRINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Allopurinol inhibits the metabolism of oral azathioprine, increasing<br />
serum azathioprine levels. Concomitant use can cause marked bone marrow suppression. If<br />
these drugs must be used together, azathioprine oral doses should be reduced to 25-30% of<br />
the usual dosage and the patient should be monitored closely for toxicity. Intravenous<br />
azathioprine does not appear to be affected by allopurinol.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Concurrent use of allopurinol and theophylline may result in<br />
theophylline toxicity (nausea, vomiting, palpitations, seizures). This interaction is<br />
more likely to occur with daily allopurinol doses of 600 mg or more.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Reports suggest that amiodarone may interfere with the clearance of<br />
cyclosporine. The risk of cyclosporine toxicity may increase.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may increase serum digoxin concentrations by up to 100%.<br />
Amiodarone may increase intestinal transit time, reduce renal clearance of digoxin,<br />
inhibit hepatic metabolism of digoxin, displace digoxin from protein-binding sites, and,<br />
in some cases, induce hypothyroidism. Empirical reduction or discontinuation of digoxin<br />
should be considered. Management also consists of monitoring clinical response or<br />
checking serum digoxin levels if toxicity is suspected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may inhibit hepatic metabolism of warfarin. A 30% to 50%<br />
reduction in warfarin dosage is recommended, as is frequent monitoring of<br />
INR.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some azoles, particulary Ketoconazole and Itraconazole, may inhibit<br />
the hepatic metabolism of cyclosporine. Serum cyclosporine concentrations and<br />
nephrotoxicity may increase fourfold. Cyclosporine dosage reductions of 80% have been<br />
necessary in some patients.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The use of HMG-CoA reductase inhibitors during azole therapy may<br />
increase CK, AST, ALT, and LDH serum levels.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">BETA BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of these drugs may cause severe bradycardia, cardiac<br />
arrest, or ventricular fibrillation. Use extreme caution using these drugs<br />
together.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL *</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The concomitant use of calcium channel blockers and beta-blockers can<br />
occasionally cause AV heart block and left-ventricular dysfunction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase levels of calcium channel<br />
blockers. Be careful using this combination of drugs, and monitor for<br />
toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CIMETIDINE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Cimetidine inhibits the hepatic metabolism of warfarin, and may<br />
increase its anticoagulant effect over a one to two week period. If given together, the<br />
INR should be monitored, and the lowest possible dose of cimetidine should be used.<br />
Another histamine-2 antagonist may be used with less risk of interaction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CLOPIDOGREL BISULFATE</font></td><br />
<br />
<td><font size="2">NSAIDs *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The coadministration of nonsteroidal antiinflammatory drugs (NSAIDs)<br />
and clopidogrel should be undertaken with extreme caution. The coadministration of<br />
clopidogrel with naproxen resulted in occult gastrointestinal blood loss in healthy<br />
volunteers. The mechanism may be due to additive platelet inhibition. Additionally,<br />
diclofenac, ibuprofen, naproxen, mefenamic acid, indomethacin and piroxicam are<br />
substrates for the cytochrome P450 isoenzyme 2C9 inhibited by clopidogrel. The clinical<br />
magnitude of this interaction is not known. The clinician should observe the patient for<br />
increased NSAID toxicity if these agents are co-administered with<br />
clopidogrel.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may significantly increase cyclosporine<br />
serum concentrations, possibly by inhibiting hepatic metabolism of cyclosporine,<br />
resulting in nephrotoxicity. Appropriate monitoring of cyclosporine serum concentrations<br />
during co-administration is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">FOSCARNET SODIUM</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Foscarnet and cyclosporine used together may increase the risk of<br />
nephrotoxicity and renal failure. If these agents are used concomitantly, consider close<br />
observation of renal function and discontinue foscarnet if needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with high doses of Gemfibrozil can<br />
cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with moderate to high doses of HMG CoA<br />
reductase inhibitors can cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL<br><br />
DILTIAZEM</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil and Diltiazem may inhibit the hepatic metabolism of<br />
cyclosporine causing increased trough and steady state levels, and the risk of<br />
nephrotoxicity. Cyclosporine levels should be monitored, and dosage should be adjusted as<br />
needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DAPSONE</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Saquinavir may competitively inhibit the metabolism of drugs that are<br />
substrates of the cytochrome P-450 (3A4) microsomal enzymatic pathway. Plasma levels of<br />
these drugs may be elevated. The patient should be monitored closely for toxicities and<br />
lower dosages of these drugs may be necessary</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Theoretically this interaction might occur with other macrolides.<br />
Patients should be closely monitored for evidence of digoxin toxicity if macrolide<br />
antibiotics and digoxin must be coadministered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The addition of itraconazole to patients stabilized on digoxin has<br />
resulted in two to fourfold increases in serum digoxin concentrations and digoxin<br />
toxicity. The mechanism is unknown. The onset of toxicity generally occurs within 9 to 13<br />
days after the start of itraconazole therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">QUINIDINE<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine significantly increases serum digoxin levels in more than<br />
90% of patients. The mechanism is related to reduced renal and biliary clearance, and<br />
reduced volume of digoxin distribution. Empiric reduction in digoxin dosing may be<br />
considered at the initiation of combination therapy. Modifications in dosage should be<br />
expected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">TETRACYCLINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Tetracyclines may increase serum levels of orally administered digoxin<br />
in about 10% of the population. The mechanism may be related to changes in intestinal<br />
flora that alter the absorption of digoxin. If these drugs must be used together, the<br />
patient should be closely monitored for digoxin toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil increases digoxin levels significantly in most patients.<br />
This important and possibly severe interaction is related to several complex mechanisms.<br />
Digoxin and verapamil have additive effects in slowing AV conduction. Verapamil also<br />
decreases the elimination of digoxin. If verapamil and digoxin are used together to<br />
control a supraventricular tachyarrhythmia, the dosage of each drug may have to be<br />
reduced.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">CLARITHROMYCIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Efavirenz increases the metabolism of clarithromycin. No dosage<br />
adjustment is recommended when these drugs are co-administered, but a rash occurs in 46%<br />
of patients administered clarithromycin and efavirenz concomitantly. Alternative therapy<br />
such as azithromycin might be considered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">INDINAVIR SULFATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Coadministration of efavirenz and indinavir causes a decreased<br />
indinavir level. The mechanism of this interaction is hepatic enzyme induction of CYP3A4<br />
by efavirenz. The dosage of indinavir should be increased from 800 mg every 8 hours to<br />
1000 mg every 8 hours when these drugs are administered concomitantly.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ENOXAPARIN<br><br />
DALTEPARIN<br><br />
TINZAPARIN</font></td><br />
<br />
<td><font size="2">HEPARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Dalteparin may increase the risk of bleeding from heparin. The<br />
mechanism is additive inhibition of thrombin and factor Xa. If these agents must be used<br />
together, extreme caution is advised, and the patient should be monitored for signs of<br />
bleeding. Other low-molecular-weight heparins (LMWHs) may interact with heparin in a<br />
similar manner.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">KETOROLAC</font></td><br />
<br />
<td><font size="2">NSAIDs *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ketorolac is contraindicated in patients concurrently receiving<br />
aspirin or NSAIDs because of the cumulative risks of inducing serious NSAID-related<br />
adverse events (peptic ulcers, gastrointestinal bleeding and/or perforation).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">When lovastatin and some macrolide antibiotics (erythromycin) have<br />
been used concomitantly in severely ill patients, severe myopathy and rhabdomyolysis have<br />
resulted. The mechanism appears to be inhibition of lovastatin metabolism by the<br />
macrolide. Patients should be instructed to report symptoms of muscle pain, weakness, or<br />
tenderness. If symptoms occur, creatine kinase should be measured. If creatine kinase is<br />
elevated, the drugs should be discontinued. A similar reaction may occur with other<br />
HMG-CoA reductase inhibitors.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">FENTANYL</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase fentanyl plasma levels. Patients<br />
should be closely observed for toxicity if these drugs are used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Gemfibrozil and lovastatin used together can cause severe myopathy and<br />
rhabdomyolysis. Combined use of gemfibrozil or clofibrate with other HMG-CoA reductase<br />
inhibitors may increase the risk of this side effect as well. If this combination must be<br />
used, the patient should be instructed to report symptoms of muscular pain, weakness, or<br />
tenderness. If creatine kinase is elevated, the drugs should be discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Immediate onset of excitement, sweating, rigidity, and hypertension<br />
can occur when monoamine oxidase inhibitors (MAOIs) are used concurrently with<br />
meperidine. Death has been reported. Similar effects have been reported with propoxyphene<br />
and fentanyl, but not with other analgesics. The combination of narcotic analgesics and<br />
MAOIs should be avoided if possible. An MAOI plus meperidine should not be used under any<br />
circumstances.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">COMT INHIBITORS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) stop the catalyst enzyme<br />
catechol-O-methyltransferase (COMT) from metabolizing levodopa to 3-O-methyldopa in the<br />
periphery, and in the brain.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SSRI ANTIDEPRESSANTS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Severe and sometimes fatal reactions involving elevations in blood<br />
pressure, hyperthermia, rigidity, and autonomic instability have occurred in patients<br />
taking SSRIs in combination with monoamine oxidase inhibitors (MAOIs). A minimum period<br />
of two weeks should separate use of these drugs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SYMPATHOMIMETIC AGENTS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sympathomimetic amines used with monoamine oxidase inhibitors may<br />
precipitate severe hypertensive reactions</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">TRICYCLIC ANTIDEPRESSANTS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants<br />
when used together may cause hyperpyretic crises, disseminated intravascular coagulation,<br />
convulsions, and death. The mechanism is unknown. Although these agents have been used<br />
together safely in many patients, some investigators recommend that tricyclic<br />
antidepressants not be used within two weeks of MAOIs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">VENLAFAXINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) used together with<br />
anti-depressants may cause severe, even fatal, reactions. The reactions reported with the<br />
newer antidepressants include hyperthermia, rigidity, myoclonus, autonomic instability,<br />
and mental status changes that range from delirium to coma. In general, MAOIs and<br />
venlafaxine or other SSRIs should be separated by 2 weeks.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NARCOTICS *<br></font></td><br />
<br />
<td><font size="2">BENZODIAZEPINES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Narcotics and benzodiazepines used together can cause excessive<br />
respiratory and CNS depression. The mechanism may be related in part to inhibition of<br />
hepatic oxidation of the benzodiazepine. Alprazolam has been most implicated in this<br />
interaction. Such interactions are more likely to occur in the benzodiazepine and<br />
narcotic "naive" patient.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NEVIRAPINE</font></td><br />
<br />
<td><font size="2">PROTEASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Because nevirapine may induce the hepatic P450 cytochrome system,<br />
reductions in plasma concentrations of protease inhibitors theoretically may occur. The<br />
manufacturer recommends that, until clinical studies provide information on dosage<br />
adjustments, protease inhibitors should not be administered concomitantly with<br />
nevirapine.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NIACIN</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Lovastatin and niacin used together may cause severe myopathy and<br />
rhabdomyolysis. Although this reaction has not been reported with concomitant use of<br />
pravastatin and niacin, patients should be instructed to report symptoms of muscle pain,<br />
weakness, or tenderness. If creatine kinase is elevated, the drugs should be<br />
discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMINOGLYCOSIDES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Aminoglycoside antibiotics may potentiate the neuromuscular blockade<br />
caused by non-depolarizing muscle relaxants. The mechanism is presynaptic acetylcholine<br />
release and reduction of postsynaptic sensitivity to acetylcholine. These combinations<br />
should be avoided if possible.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">POLYMYXIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Polymyxin B may prolong apnea and respiratory paralysis after use of<br />
neuromuscular blocking agents. The mechanism may be related to decreased intracellular<br />
potassium or decreased ionized serum calcium. Intravenous calcium administration may be<br />
helpful in reversing the paralysis.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">There may be an increased risk of CNS or respiratory depression when<br />
this combination of drugs is used.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Phenytoin may significantly reduce cyclosporine serum concentrations.<br />
The mechanism may be inhibition of cyclosporine absorption or induction of hepatic<br />
metabolism or both. This interaction may occur with ethotoin, fosphenytoin, and<br />
mephenytoin as well. Cyclosporine levels should be closely monitored during concomitant<br />
therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Dilantin can accelerate the metabolism of ritonavir thus reducing its<br />
plasma concentration. Ritonavir can raise or lower dilantin levels. Use caution if these<br />
drugs must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">K-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of potassium-sparing diuretics and potassium<br />
preparations may result in hyperkalemia. These agents should not be used together unless<br />
the patient has documented hypokalemia while taking either agent alone. If this<br />
combination is used, the patient should be given dietary counseling and monitored very<br />
closely for hyperkalemia.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PROCAINAMIDE</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some beta-blockers may decrease the clearance and increase the serum<br />
level of procainamide. Data are available for metoprolol and propranolol<br />
only.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone can increase quinidine concentrations inducing prolongation<br />
of the QT interval. Quinidine dose may need to be reduced by 50% if amiodarone is<br />
added.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil may increase plasma quinidine concentrations. While these<br />
drugs can be given together safely, significant adverse side effects can occur,<br />
especially in patients with hypertrophic or dilated cardiomyopathies and in patients on<br />
higher doses of either drug. If these drugs must be given together, lower doses of<br />
quinidine are needed to achieve a given plasma concentration and clinical response.<br />
Clinical and electrocardiographic monitoring for quinidine toxicity (such as hypotension,<br />
arrhythmias, and AV block) is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may interfere with the metabolism of meperidine. Large<br />
increases in serum meperidine concentrations may result. The concomitant use of these<br />
agents is contraindicated by the manufacturer and should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir capsules and ritonavir oral solution contain alcohol, which<br />
may cause a reaction when this drug is used with disulfiram or metronidazole.<br />
Simultaneous use should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The plasma concentration of saquinavir mesylate (Invirase) is<br />
increased markedly (29-fold) by ritonavir. The safety of their concurrent use has not<br />
been established. The newer form of saquinavir (Fortovase) is more bioavailable.<br />
Therefore, this interaction is less relevant for saquinavir (Fortovase).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may cause large fluctuations in the serum concentrations of<br />
warfarin. If ritonavir and warfarin must be used together, frequent monitoring of the INR<br />
is strongly recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFADIAZINE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some sulfonamides inhibit the hepatic metabolism of phenytoin. Serum<br />
phenytoin levels and risk of toxicity may be increased. Data are available for<br />
sulfadiazine and sulfamethizole. Management consists of monitoring the patient for signs<br />
and symptoms of phenytoin toxicity, checking serum levels, and decreasing phenytoin<br />
dosage as necessary.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFAMETHOXAZOLE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sulfonamides increase the level of warfarin-(S) isomer by an unknown<br />
mechanism. Hypoprothrombinemic effect is enhanced. . Frequent monitoring of the INR is<br />
recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TACROLIMUS</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">In vitro and in vivo data suggest that erythromycin may inhibit the<br />
hepatic metabolism of tacrolimus. Data from two case reports suggest that concomitant use<br />
of erythromycin may result in elevated serum tacrolimus concentrations. If these drugs<br />
are used concomitantly, plasma tacrolimus concentrations should be carefully monitored,<br />
with reductions in dosage to prevent nephrotoxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">CIPROFLOXACIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ciprofloxacin can significantly reduce the clearance of theophylline<br />
by inhibition of hepatic metabolism. The interaction can result in theophylline toxicity,<br />
and may increase the risk of seizures, especially in the elderly. The patient should be<br />
monitored for theophylline toxicity and elevated serum levels while also taking<br />
ciprofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolides (erythromycin and troleandomycin) inhibit theophylline<br />
metabolism. During coadministration, serum theophylline levels and risk of theophylline<br />
toxicity are increased. Conversely, theophylline increases the renal clearance of<br />
erythromycin and decreases erythromycin concentrations. Monitoring of theophylline levels<br />
and efficacy is recommended when erythromycin is added to or discontinued from the<br />
patient's regimen. [Dirithromycin [?on formulary]appears to increase the plasma clearance<br />
of theophylline, and plasma theophylline concentrations can be decreased by approximately<br />
26%. The dirithromycin-theophylline interaction is unlikely to be clinically significant<br />
enough to modify treatment and outcome.] The effects of azithromycin and clarithromycin<br />
on the pharmacokinetic disposition of theophylline are not known. Azithromycin, however,<br />
does not appear to interfere with theophylline levels and may be the macrolide of choice<br />
for patients on theophylline therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with phenytoin may cause a 25% increase in<br />
phenytoin plasma concentration, particularly in patients receiving phenytoin twice a day.<br />
Additionally, the concentration of topiramate decreased by 48%. Addition or withdrawal of<br />
hydantoins during therapy with topiramate may require a dose adjustment of topiramate<br />
and/or the hydantoin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">VALPROATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with valproic acid may lead to an 11% decrease<br />
in valproic acid plasma concentration. Additionally, the concentration of topiramate<br />
decreased by 14%. The mechanism of action may be increased metabolism of both drugs.<br />
Addition or withdrawal of valproic acid during adjunctive therapy with topiramate may<br />
require a dose adjustment of topiramate and/or valproic acid.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE<br><br />
KETOCONAZOLE<br><br />
FLUCONAZOLE<br><br />
MICONAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">These drugs may increase the effect of warfarin. The mechanism is<br />
unknown. Close monitoring of the INR is recommended if these drugs must be used<br />
together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">CELECOXIB<br><br />
ROFECOXIB</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Risk of bleeding is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may inhibit the hepatic metabolism of<br />
warfarin resulting in an enhanced anticoagulant effect. Data are available for<br />
erythromycin and clarithromycin only. Close monitoring of the INR is recommended if a<br />
macrolide antimicrobial and warfarin must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Metronidazole may inhibit the metabolism of warfarin and increase its<br />
anticoagulant effect. The INR should be monitored closely.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Warfarin can increase phenytoin half-life and serum concentrations.<br />
The addition of phenytoin to warfarin therapy can increase the INR. The mechanism is not<br />
known. Serum phenytoin concentrations and INR should be monitored in patients receiving<br />
this combination.</font></td><br />
</tr><br />
<br />
<tr align="left"><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINOLONES*<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Most fluoroquinolones can inhibit the metabolism of warfarin<br />
increasing the INR. Patients on concomitant therapy should be monitored for elevations in<br />
INR. However, one study of sixteen volunteers reported a lack of interaction between<br />
warfarin and levofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine can induce hypoprothrombinemia, thus raising the INR and<br />
increasing the risk of bleeding.<br />
</td></tr></table></div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug-Drug_Interaction_RulesDrug-Drug Interaction Rules2008-02-20T20:29:49Z<p>AdamWright: </p>
<hr />
<div>These drug interactions are based on a set released by the Beth-Israel Deaconess Hospital, and are used here with permission. [http://geekdoctor.blogspot.com/2008/02/provider-order-entry.html (1)] [http://mycourses.med.harvard.edu/ec_res/nt/8AD4BE90-283F-4A6A-AADB-9F0DB529FA1E/drugdrug.doc (2)]<br />
<br />
<table border="1" cellpadding="1" cellspacing="2"><br />
<tr><br />
<td><font size="2"><b>Generic Drug Name or Category</b></font></td><br />
<br />
<td><font size="2"><b>Interacts With</b></font></td><br />
<br />
<td><font size="2"><b>Severity</b></font></td><br />
<br />
<td><font size="2"><b>Text</b></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">K-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Diuretics and ACE inhibitors used together may cause hypotension. The<br />
combination of ACE inhibitors and potassium-sparing diuretics may cause significant<br />
hyperkalemia. This effect is particularly significant in patients with renal<br />
insufficiency.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *</font></td><br />
<br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">ACE inhibitors may decrease aldosterone causing hyperkalemia. When ACE<br />
inhibitors are coadministered with potassium-containing products, the risk of<br />
hyperkalemia is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">AZATHIOPRINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Allopurinol inhibits the metabolism of oral azathioprine, increasing<br />
serum azathioprine levels. Concomitant use can cause marked bone marrow suppression. If<br />
these drugs must be used together, azathioprine oral doses should be reduced to 25-30% of<br />
the usual dosage and the patient should be monitored closely for toxicity. Intravenous<br />
azathioprine does not appear to be affected by allopurinol.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Concurrent use of allopurinol and theophylline may result in<br />
theophylline toxicity (nausea, vomiting, palpitations, seizures). This interaction is<br />
more likely to occur with daily allopurinol doses of 600 mg or more.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Reports suggest that amiodarone may interfere with the clearance of<br />
cyclosporine. The risk of cyclosporine toxicity may increase.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may increase serum digoxin concentrations by up to 100%.<br />
Amiodarone may increase intestinal transit time, reduce renal clearance of digoxin,<br />
inhibit hepatic metabolism of digoxin, displace digoxin from protein-binding sites, and,<br />
in some cases, induce hypothyroidism. Empirical reduction or discontinuation of digoxin<br />
should be considered. Management also consists of monitoring clinical response or<br />
checking serum digoxin levels if toxicity is suspected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may inhibit hepatic metabolism of warfarin. A 30% to 50%<br />
reduction in warfarin dosage is recommended, as is frequent monitoring of<br />
INR.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some azoles, particulary Ketoconazole and Itraconazole, may inhibit<br />
the hepatic metabolism of cyclosporine. Serum cyclosporine concentrations and<br />
nephrotoxicity may increase fourfold. Cyclosporine dosage reductions of 80% have been<br />
necessary in some patients.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The use of HMG-CoA reductase inhibitors during azole therapy may<br />
increase CK, AST, ALT, and LDH serum levels.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">BETA BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of these drugs may cause severe bradycardia, cardiac<br />
arrest, or ventricular fibrillation. Use extreme caution using these drugs<br />
together.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL *</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The concomitant use of calcium channel blockers and beta-blockers can<br />
occasionally cause AV heart block and left-ventricular dysfunction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase levels of calcium channel<br />
blockers. Be careful using this combination of drugs, and monitor for<br />
toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CIMETIDINE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Cimetidine inhibits the hepatic metabolism of warfarin, and may<br />
increase its anticoagulant effect over a one to two week period. If given together, the<br />
INR should be monitored, and the lowest possible dose of cimetidine should be used.<br />
Another histamine-2 antagonist may be used with less risk of interaction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CLOPIDOGREL BISULFATE</font></td><br />
<br />
<td><font size="2">NSAIDs *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The coadministration of nonsteroidal antiinflammatory drugs (NSAIDs)<br />
and clopidogrel should be undertaken with extreme caution. The coadministration of<br />
clopidogrel with naproxen resulted in occult gastrointestinal blood loss in healthy<br />
volunteers. The mechanism may be due to additive platelet inhibition. Additionally,<br />
diclofenac, ibuprofen, naproxen, mefenamic acid, indomethacin and piroxicam are<br />
substrates for the cytochrome P450 isoenzyme 2C9 inhibited by clopidogrel. The clinical<br />
magnitude of this interaction is not known. The clinician should observe the patient for<br />
increased NSAID toxicity if these agents are co-administered with<br />
clopidogrel.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may significantly increase cyclosporine<br />
serum concentrations, possibly by inhibiting hepatic metabolism of cyclosporine,<br />
resulting in nephrotoxicity. Appropriate monitoring of cyclosporine serum concentrations<br />
during co-administration is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">FOSCARNET SODIUM</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Foscarnet and cyclosporine used together may increase the risk of<br />
nephrotoxicity and renal failure. If these agents are used concomitantly, consider close<br />
observation of renal function and discontinue foscarnet if needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with high doses of Gemfibrozil can<br />
cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with moderate to high doses of HMG CoA<br />
reductase inhibitors can cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL<br><br />
DILTIAZEM</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil and Diltiazem may inhibit the hepatic metabolism of<br />
cyclosporine causing increased trough and steady state levels, and the risk of<br />
nephrotoxicity. Cyclosporine levels should be monitored, and dosage should be adjusted as<br />
needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DAPSONE</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Saquinavir may competitively inhibit the metabolism of drugs that are<br />
substrates of the cytochrome P-450 (3A4) microsomal enzymatic pathway. Plasma levels of<br />
these drugs may be elevated. The patient should be monitored closely for toxicities and<br />
lower dosages of these drugs may be necessary</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Theoretically this interaction might occur with other macrolides.<br />
Patients should be closely monitored for evidence of digoxin toxicity if macrolide<br />
antibiotics and digoxin must be coadministered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The addition of itraconazole to patients stabilized on digoxin has<br />
resulted in two to fourfold increases in serum digoxin concentrations and digoxin<br />
toxicity. The mechanism is unknown. The onset of toxicity generally occurs within 9 to 13<br />
days after the start of itraconazole therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">QUINIDINE<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine significantly increases serum digoxin levels in more than<br />
90% of patients. The mechanism is related to reduced renal and biliary clearance, and<br />
reduced volume of digoxin distribution. Empiric reduction in digoxin dosing may be<br />
considered at the initiation of combination therapy. Modifications in dosage should be<br />
expected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">TETRACYCLINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Tetracyclines may increase serum levels of orally administered digoxin<br />
in about 10% of the population. The mechanism may be related to changes in intestinal<br />
flora that alter the absorption of digoxin. If these drugs must be used together, the<br />
patient should be closely monitored for digoxin toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil increases digoxin levels significantly in most patients.<br />
This important and possibly severe interaction is related to several complex mechanisms.<br />
Digoxin and verapamil have additive effects in slowing AV conduction. Verapamil also<br />
decreases the elimination of digoxin. If verapamil and digoxin are used together to<br />
control a supraventricular tachyarrhythmia, the dosage of each drug may have to be<br />
reduced.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">CLARITHROMYCIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Efavirenz increases the metabolism of clarithromycin. No dosage<br />
adjustment is recommended when these drugs are co-administered, but a rash occurs in 46%<br />
of patients administered clarithromycin and efavirenz concomitantly. Alternative therapy<br />
such as azithromycin might be considered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">INDINAVIR SULFATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Coadministration of efavirenz and indinavir causes a decreased<br />
indinavir level. The mechanism of this interaction is hepatic enzyme induction of CYP3A4<br />
by efavirenz. The dosage of indinavir should be increased from 800 mg every 8 hours to<br />
1000 mg every 8 hours when these drugs are administered concomitantly.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ENOXAPARIN<br><br />
DALTEPARIN<br><br />
TINZAPARIN</font></td><br />
<br />
<td><font size="2">HEPARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Dalteparin may increase the risk of bleeding from heparin. The<br />
mechanism is additive inhibition of thrombin and factor Xa. If these agents must be used<br />
together, extreme caution is advised, and the patient should be monitored for signs of<br />
bleeding. Other low-molecular-weight heparins (LMWHs) may interact with heparin in a<br />
similar manner.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">KETOROLAC</font></td><br />
<br />
<td><font size="2">NSAIDs *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ketorolac is contraindicated in patients concurrently receiving<br />
aspirin or NSAIDs because of the cumulative risks of inducing serious NSAID-related<br />
adverse events (peptic ulcers, gastrointestinal bleeding and/or perforation).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">When lovastatin and some macrolide antibiotics (erythromycin) have<br />
been used concomitantly in severely ill patients, severe myopathy and rhabdomyolysis have<br />
resulted. The mechanism appears to be inhibition of lovastatin metabolism by the<br />
macrolide. Patients should be instructed to report symptoms of muscle pain, weakness, or<br />
tenderness. If symptoms occur, creatine kinase should be measured. If creatine kinase is<br />
elevated, the drugs should be discontinued. A similar reaction may occur with other<br />
HMG-CoA reductase inhibitors.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">FENTANYL</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase fentanyl plasma levels. Patients<br />
should be closely observed for toxicity if these drugs are used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Gemfibrozil and lovastatin used together can cause severe myopathy and<br />
rhabdomyolysis. Combined use of gemfibrozil or clofibrate with other HMG-CoA reductase<br />
inhibitors may increase the risk of this side effect as well. If this combination must be<br />
used, the patient should be instructed to report symptoms of muscular pain, weakness, or<br />
tenderness. If creatine kinase is elevated, the drugs should be discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Immediate onset of excitement, sweating, rigidity, and hypertension<br />
can occur when monoamine oxidase inhibitors (MAOIs) are used concurrently with<br />
meperidine. Death has been reported. Similar effects have been reported with propoxyphene<br />
and fentanyl, but not with other analgesics. The combination of narcotic analgesics and<br />
MAOIs should be avoided if possible. An MAOI plus meperidine should not be used under any<br />
circumstances.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">COMT INHIBITORS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) stop the catalyst enzyme<br />
catechol-O-methyltransferase (COMT) from metabolizing levodopa to 3-O-methyldopa in the<br />
periphery, and in the brain.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SSRI ANTIDEPRESSANTS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Severe and sometimes fatal reactions involving elevations in blood<br />
pressure, hyperthermia, rigidity, and autonomic instability have occurred in patients<br />
taking SSRIs in combination with monoamine oxidase inhibitors (MAOIs). A minimum period<br />
of two weeks should separate use of these drugs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SYMPATHOMIMETIC AGENTS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sympathomimetic amines used with monoamine oxidase inhibitors may<br />
precipitate severe hypertensive reactions</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">TRICYCLIC ANTIDEPRESSANTS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants<br />
when used together may cause hyperpyretic crises, disseminated intravascular coagulation,<br />
convulsions, and death. The mechanism is unknown. Although these agents have been used<br />
together safely in many patients, some investigators recommend that tricyclic<br />
antidepressants not be used within two weeks of MAOIs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">VENLAFAXINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) used together with<br />
anti-depressants may cause severe, even fatal, reactions. The reactions reported with the<br />
newer antidepressants include hyperthermia, rigidity, myoclonus, autonomic instability,<br />
and mental status changes that range from delirium to coma. In general, MAOIs and<br />
venlafaxine or other SSRIs should be separated by 2 weeks.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NARCOTICS *<br></font></td><br />
<br />
<td><font size="2">BENZODIAZEPINES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Narcotics and benzodiazepines used together can cause excessive<br />
respiratory and CNS depression. The mechanism may be related in part to inhibition of<br />
hepatic oxidation of the benzodiazepine. Alprazolam has been most implicated in this<br />
interaction. Such interactions are more likely to occur in the benzodiazepine and<br />
narcotic "naive" patient.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NEVIRAPINE</font></td><br />
<br />
<td><font size="2">PROTEASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Because nevirapine may induce the hepatic P450 cytochrome system,<br />
reductions in plasma concentrations of protease inhibitors theoretically may occur. The<br />
manufacturer recommends that, until clinical studies provide information on dosage<br />
adjustments, protease inhibitors should not be administered concomitantly with<br />
nevirapine.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NIACIN</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Lovastatin and niacin used together may cause severe myopathy and<br />
rhabdomyolysis. Although this reaction has not been reported with concomitant use of<br />
pravastatin and niacin, patients should be instructed to report symptoms of muscle pain,<br />
weakness, or tenderness. If creatine kinase is elevated, the drugs should be<br />
discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMINOGLYCOSIDES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Aminoglycoside antibiotics may potentiate the neuromuscular blockade<br />
caused by non-depolarizing muscle relaxants. The mechanism is presynaptic acetylcholine<br />
release and reduction of postsynaptic sensitivity to acetylcholine. These combinations<br />
should be avoided if possible.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">POLYMYXIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Polymyxin B may prolong apnea and respiratory paralysis after use of<br />
neuromuscular blocking agents. The mechanism may be related to decreased intracellular<br />
potassium or decreased ionized serum calcium. Intravenous calcium administration may be<br />
helpful in reversing the paralysis.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">There may be an increased risk of CNS or respiratory depression when<br />
this combination of drugs is used.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Phenytoin may significantly reduce cyclosporine serum concentrations.<br />
The mechanism may be inhibition of cyclosporine absorption or induction of hepatic<br />
metabolism or both. This interaction may occur with ethotoin, fosphenytoin, and<br />
mephenytoin as well. Cyclosporine levels should be closely monitored during concomitant<br />
therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Dilantin can accelerate the metabolism of ritonavir thus reducing its<br />
plasma concentration. Ritonavir can raise or lower dilantin levels. Use caution if these<br />
drugs must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">K-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of potassium-sparing diuretics and potassium<br />
preparations may result in hyperkalemia. These agents should not be used together unless<br />
the patient has documented hypokalemia while taking either agent alone. If this<br />
combination is used, the patient should be given dietary counseling and monitored very<br />
closely for hyperkalemia.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PROCAINAMIDE</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some beta-blockers may decrease the clearance and increase the serum<br />
level of procainamide. Data are available for metoprolol and propranolol<br />
only.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone can increase quinidine concentrations inducing prolongation<br />
of the QT interval. Quinidine dose may need to be reduced by 50% if amiodarone is<br />
added.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil may increase plasma quinidine concentrations. While these<br />
drugs can be given together safely, significant adverse side effects can occur,<br />
especially in patients with hypertrophic or dilated cardiomyopathies and in patients on<br />
higher doses of either drug. If these drugs must be given together, lower doses of<br />
quinidine are needed to achieve a given plasma concentration and clinical response.<br />
Clinical and electrocardiographic monitoring for quinidine toxicity (such as hypotension,<br />
arrhythmias, and AV block) is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may interfere with the metabolism of meperidine. Large<br />
increases in serum meperidine concentrations may result. The concomitant use of these<br />
agents is contraindicated by the manufacturer and should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir capsules and ritonavir oral solution contain alcohol, which<br />
may cause a reaction when this drug is used with disulfiram or metronidazole.<br />
Simultaneous use should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The plasma concentration of saquinavir mesylate (Invirase) is<br />
increased markedly (29-fold) by ritonavir. The safety of their concurrent use has not<br />
been established. The newer form of saquinavir (Fortovase) is more bioavailable.<br />
Therefore, this interaction is less relevant for saquinavir (Fortovase).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may cause large fluctuations in the serum concentrations of<br />
warfarin. If ritonavir and warfarin must be used together, frequent monitoring of the INR<br />
is strongly recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFADIAZINE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some sulfonamides inhibit the hepatic metabolism of phenytoin. Serum<br />
phenytoin levels and risk of toxicity may be increased. Data are available for<br />
sulfadiazine and sulfamethizole. Management consists of monitoring the patient for signs<br />
and symptoms of phenytoin toxicity, checking serum levels, and decreasing phenytoin<br />
dosage as necessary.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFAMETHOXAZOLE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sulfonamides increase the level of warfarin-(S) isomer by an unknown<br />
mechanism. Hypoprothrombinemic effect is enhanced. . Frequent monitoring of the INR is<br />
recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TACROLIMUS</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">In vitro and in vivo data suggest that erythromycin may inhibit the<br />
hepatic metabolism of tacrolimus. Data from two case reports suggest that concomitant use<br />
of erythromycin may result in elevated serum tacrolimus concentrations. If these drugs<br />
are used concomitantly, plasma tacrolimus concentrations should be carefully monitored,<br />
with reductions in dosage to prevent nephrotoxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">CIPROFLOXACIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ciprofloxacin can significantly reduce the clearance of theophylline<br />
by inhibition of hepatic metabolism. The interaction can result in theophylline toxicity,<br />
and may increase the risk of seizures, especially in the elderly. The patient should be<br />
monitored for theophylline toxicity and elevated serum levels while also taking<br />
ciprofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolides (erythromycin and troleandomycin) inhibit theophylline<br />
metabolism. During coadministration, serum theophylline levels and risk of theophylline<br />
toxicity are increased. Conversely, theophylline increases the renal clearance of<br />
erythromycin and decreases erythromycin concentrations. Monitoring of theophylline levels<br />
and efficacy is recommended when erythromycin is added to or discontinued from the<br />
patient's regimen. [Dirithromycin [?on formulary]appears to increase the plasma clearance<br />
of theophylline, and plasma theophylline concentrations can be decreased by approximately<br />
26%. The dirithromycin-theophylline interaction is unlikely to be clinically significant<br />
enough to modify treatment and outcome.] The effects of azithromycin and clarithromycin<br />
on the pharmacokinetic disposition of theophylline are not known. Azithromycin, however,<br />
does not appear to interfere with theophylline levels and may be the macrolide of choice<br />
for patients on theophylline therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with phenytoin may cause a 25% increase in<br />
phenytoin plasma concentration, particularly in patients receiving phenytoin twice a day.<br />
Additionally, the concentration of topiramate decreased by 48%. Addition or withdrawal of<br />
hydantoins during therapy with topiramate may require a dose adjustment of topiramate<br />
and/or the hydantoin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">VALPROATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with valproic acid may lead to an 11% decrease<br />
in valproic acid plasma concentration. Additionally, the concentration of topiramate<br />
decreased by 14%. The mechanism of action may be increased metabolism of both drugs.<br />
Addition or withdrawal of valproic acid during adjunctive therapy with topiramate may<br />
require a dose adjustment of topiramate and/or valproic acid.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE<br><br />
KETOCONAZOLE<br><br />
FLUCONAZOLE<br><br />
MICONAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">These drugs may increase the effect of warfarin. The mechanism is<br />
unknown. Close monitoring of the INR is recommended if these drugs must be used<br />
together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">CELECOXIB<br><br />
ROFECOXIB</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Risk of bleeding is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may inhibit the hepatic metabolism of<br />
warfarin resulting in an enhanced anticoagulant effect. Data are available for<br />
erythromycin and clarithromycin only. Close monitoring of the INR is recommended if a<br />
macrolide antimicrobial and warfarin must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Metronidazole may inhibit the metabolism of warfarin and increase its<br />
anticoagulant effect. The INR should be monitored closely.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Warfarin can increase phenytoin half-life and serum concentrations.<br />
The addition of phenytoin to warfarin therapy can increase the INR. The mechanism is not<br />
known. Serum phenytoin concentrations and INR should be monitored in patients receiving<br />
this combination.</font></td><br />
</tr><br />
<br />
<tr align="left"><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINOLONES*<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Most fluoroquinolones can inhibit the metabolism of warfarin<br />
increasing the INR. Patients on concomitant therapy should be monitored for elevations in<br />
INR. However, one study of sixteen volunteers reported a lack of interaction between<br />
warfarin and levofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine can induce hypoprothrombinemia, thus raising the INR and<br />
increasing the risk of bleeding.<br />
</td></tr></table></div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug-Drug_Interaction_RulesDrug-Drug Interaction Rules2008-02-20T20:26:24Z<p>AdamWright: </p>
<hr />
<div><table border="1" cellpadding="1" cellspacing="2"><br />
<tr><br />
<td><font size="2"><b>Generic Drug Name or Category</b></font></td><br />
<br />
<td><font size="2"><b>Interacts With</b></font></td><br />
<br />
<td><font size="2"><b>Severity</b></font></td><br />
<br />
<td><font size="2"><b>Text</b></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">K-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Diuretics and ACE inhibitors used together may cause hypotension. The<br />
combination of ACE inhibitors and potassium-sparing diuretics may cause significant<br />
hyperkalemia. This effect is particularly significant in patients with renal<br />
insufficiency.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *</font></td><br />
<br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">ACE inhibitors may decrease aldosterone causing hyperkalemia. When ACE<br />
inhibitors are coadministered with potassium-containing products, the risk of<br />
hyperkalemia is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">AZATHIOPRINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Allopurinol inhibits the metabolism of oral azathioprine, increasing<br />
serum azathioprine levels. Concomitant use can cause marked bone marrow suppression. If<br />
these drugs must be used together, azathioprine oral doses should be reduced to 25-30% of<br />
the usual dosage and the patient should be monitored closely for toxicity. Intravenous<br />
azathioprine does not appear to be affected by allopurinol.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Concurrent use of allopurinol and theophylline may result in<br />
theophylline toxicity (nausea, vomiting, palpitations, seizures). This interaction is<br />
more likely to occur with daily allopurinol doses of 600 mg or more.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Reports suggest that amiodarone may interfere with the clearance of<br />
cyclosporine. The risk of cyclosporine toxicity may increase.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may increase serum digoxin concentrations by up to 100%.<br />
Amiodarone may increase intestinal transit time, reduce renal clearance of digoxin,<br />
inhibit hepatic metabolism of digoxin, displace digoxin from protein-binding sites, and,<br />
in some cases, induce hypothyroidism. Empirical reduction or discontinuation of digoxin<br />
should be considered. Management also consists of monitoring clinical response or<br />
checking serum digoxin levels if toxicity is suspected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may inhibit hepatic metabolism of warfarin. A 30% to 50%<br />
reduction in warfarin dosage is recommended, as is frequent monitoring of<br />
INR.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some azoles, particulary Ketoconazole and Itraconazole, may inhibit<br />
the hepatic metabolism of cyclosporine. Serum cyclosporine concentrations and<br />
nephrotoxicity may increase fourfold. Cyclosporine dosage reductions of 80% have been<br />
necessary in some patients.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The use of HMG-CoA reductase inhibitors during azole therapy may<br />
increase CK, AST, ALT, and LDH serum levels.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">BETA BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of these drugs may cause severe bradycardia, cardiac<br />
arrest, or ventricular fibrillation. Use extreme caution using these drugs<br />
together.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL *</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The concomitant use of calcium channel blockers and beta-blockers can<br />
occasionally cause AV heart block and left-ventricular dysfunction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase levels of calcium channel<br />
blockers. Be careful using this combination of drugs, and monitor for<br />
toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CIMETIDINE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Cimetidine inhibits the hepatic metabolism of warfarin, and may<br />
increase its anticoagulant effect over a one to two week period. If given together, the<br />
INR should be monitored, and the lowest possible dose of cimetidine should be used.<br />
Another histamine-2 antagonist may be used with less risk of interaction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CLOPIDOGREL BISULFATE</font></td><br />
<br />
<td><font size="2">NSAIDs *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The coadministration of nonsteroidal antiinflammatory drugs (NSAIDs)<br />
and clopidogrel should be undertaken with extreme caution. The coadministration of<br />
clopidogrel with naproxen resulted in occult gastrointestinal blood loss in healthy<br />
volunteers. The mechanism may be due to additive platelet inhibition. Additionally,<br />
diclofenac, ibuprofen, naproxen, mefenamic acid, indomethacin and piroxicam are<br />
substrates for the cytochrome P450 isoenzyme 2C9 inhibited by clopidogrel. The clinical<br />
magnitude of this interaction is not known. The clinician should observe the patient for<br />
increased NSAID toxicity if these agents are co-administered with<br />
clopidogrel.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may significantly increase cyclosporine<br />
serum concentrations, possibly by inhibiting hepatic metabolism of cyclosporine,<br />
resulting in nephrotoxicity. Appropriate monitoring of cyclosporine serum concentrations<br />
during co-administration is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">FOSCARNET SODIUM</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Foscarnet and cyclosporine used together may increase the risk of<br />
nephrotoxicity and renal failure. If these agents are used concomitantly, consider close<br />
observation of renal function and discontinue foscarnet if needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with high doses of Gemfibrozil can<br />
cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with moderate to high doses of HMG CoA<br />
reductase inhibitors can cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL<br><br />
DILTIAZEM</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil and Diltiazem may inhibit the hepatic metabolism of<br />
cyclosporine causing increased trough and steady state levels, and the risk of<br />
nephrotoxicity. Cyclosporine levels should be monitored, and dosage should be adjusted as<br />
needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DAPSONE</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Saquinavir may competitively inhibit the metabolism of drugs that are<br />
substrates of the cytochrome P-450 (3A4) microsomal enzymatic pathway. Plasma levels of<br />
these drugs may be elevated. The patient should be monitored closely for toxicities and<br />
lower dosages of these drugs may be necessary</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Theoretically this interaction might occur with other macrolides.<br />
Patients should be closely monitored for evidence of digoxin toxicity if macrolide<br />
antibiotics and digoxin must be coadministered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The addition of itraconazole to patients stabilized on digoxin has<br />
resulted in two to fourfold increases in serum digoxin concentrations and digoxin<br />
toxicity. The mechanism is unknown. The onset of toxicity generally occurs within 9 to 13<br />
days after the start of itraconazole therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">QUINIDINE<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine significantly increases serum digoxin levels in more than<br />
90% of patients. The mechanism is related to reduced renal and biliary clearance, and<br />
reduced volume of digoxin distribution. Empiric reduction in digoxin dosing may be<br />
considered at the initiation of combination therapy. Modifications in dosage should be<br />
expected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">TETRACYCLINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Tetracyclines may increase serum levels of orally administered digoxin<br />
in about 10% of the population. The mechanism may be related to changes in intestinal<br />
flora that alter the absorption of digoxin. If these drugs must be used together, the<br />
patient should be closely monitored for digoxin toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil increases digoxin levels significantly in most patients.<br />
This important and possibly severe interaction is related to several complex mechanisms.<br />
Digoxin and verapamil have additive effects in slowing AV conduction. Verapamil also<br />
decreases the elimination of digoxin. If verapamil and digoxin are used together to<br />
control a supraventricular tachyarrhythmia, the dosage of each drug may have to be<br />
reduced.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">CLARITHROMYCIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Efavirenz increases the metabolism of clarithromycin. No dosage<br />
adjustment is recommended when these drugs are co-administered, but a rash occurs in 46%<br />
of patients administered clarithromycin and efavirenz concomitantly. Alternative therapy<br />
such as azithromycin might be considered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">INDINAVIR SULFATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Coadministration of efavirenz and indinavir causes a decreased<br />
indinavir level. The mechanism of this interaction is hepatic enzyme induction of CYP3A4<br />
by efavirenz. The dosage of indinavir should be increased from 800 mg every 8 hours to<br />
1000 mg every 8 hours when these drugs are administered concomitantly.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ENOXAPARIN<br><br />
DALTEPARIN<br><br />
TINZAPARIN</font></td><br />
<br />
<td><font size="2">HEPARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Dalteparin may increase the risk of bleeding from heparin. The<br />
mechanism is additive inhibition of thrombin and factor Xa. If these agents must be used<br />
together, extreme caution is advised, and the patient should be monitored for signs of<br />
bleeding. Other low-molecular-weight heparins (LMWHs) may interact with heparin in a<br />
similar manner.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">KETOROLAC</font></td><br />
<br />
<td><font size="2">NSAIDs *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ketorolac is contraindicated in patients concurrently receiving<br />
aspirin or NSAIDs because of the cumulative risks of inducing serious NSAID-related<br />
adverse events (peptic ulcers, gastrointestinal bleeding and/or perforation).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">When lovastatin and some macrolide antibiotics (erythromycin) have<br />
been used concomitantly in severely ill patients, severe myopathy and rhabdomyolysis have<br />
resulted. The mechanism appears to be inhibition of lovastatin metabolism by the<br />
macrolide. Patients should be instructed to report symptoms of muscle pain, weakness, or<br />
tenderness. If symptoms occur, creatine kinase should be measured. If creatine kinase is<br />
elevated, the drugs should be discontinued. A similar reaction may occur with other<br />
HMG-CoA reductase inhibitors.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">FENTANYL</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase fentanyl plasma levels. Patients<br />
should be closely observed for toxicity if these drugs are used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Gemfibrozil and lovastatin used together can cause severe myopathy and<br />
rhabdomyolysis. Combined use of gemfibrozil or clofibrate with other HMG-CoA reductase<br />
inhibitors may increase the risk of this side effect as well. If this combination must be<br />
used, the patient should be instructed to report symptoms of muscular pain, weakness, or<br />
tenderness. If creatine kinase is elevated, the drugs should be discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Immediate onset of excitement, sweating, rigidity, and hypertension<br />
can occur when monoamine oxidase inhibitors (MAOIs) are used concurrently with<br />
meperidine. Death has been reported. Similar effects have been reported with propoxyphene<br />
and fentanyl, but not with other analgesics. The combination of narcotic analgesics and<br />
MAOIs should be avoided if possible. An MAOI plus meperidine should not be used under any<br />
circumstances.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">COMT INHIBITORS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) stop the catalyst enzyme<br />
catechol-O-methyltransferase (COMT) from metabolizing levodopa to 3-O-methyldopa in the<br />
periphery, and in the brain.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SSRI ANTIDEPRESSANTS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Severe and sometimes fatal reactions involving elevations in blood<br />
pressure, hyperthermia, rigidity, and autonomic instability have occurred in patients<br />
taking SSRIs in combination with monoamine oxidase inhibitors (MAOIs). A minimum period<br />
of two weeks should separate use of these drugs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SYMPATHOMIMETIC AGENTS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sympathomimetic amines used with monoamine oxidase inhibitors may<br />
precipitate severe hypertensive reactions</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">TRICYCLIC ANTIDEPRESSANTS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants<br />
when used together may cause hyperpyretic crises, disseminated intravascular coagulation,<br />
convulsions, and death. The mechanism is unknown. Although these agents have been used<br />
together safely in many patients, some investigators recommend that tricyclic<br />
antidepressants not be used within two weeks of MAOIs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">VENLAFAXINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) used together with<br />
anti-depressants may cause severe, even fatal, reactions. The reactions reported with the<br />
newer antidepressants include hyperthermia, rigidity, myoclonus, autonomic instability,<br />
and mental status changes that range from delirium to coma. In general, MAOIs and<br />
venlafaxine or other SSRIs should be separated by 2 weeks.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NARCOTICS *<br></font></td><br />
<br />
<td><font size="2">BENZODIAZEPINES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Narcotics and benzodiazepines used together can cause excessive<br />
respiratory and CNS depression. The mechanism may be related in part to inhibition of<br />
hepatic oxidation of the benzodiazepine. Alprazolam has been most implicated in this<br />
interaction. Such interactions are more likely to occur in the benzodiazepine and<br />
narcotic "naive" patient.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NEVIRAPINE</font></td><br />
<br />
<td><font size="2">PROTEASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Because nevirapine may induce the hepatic P450 cytochrome system,<br />
reductions in plasma concentrations of protease inhibitors theoretically may occur. The<br />
manufacturer recommends that, until clinical studies provide information on dosage<br />
adjustments, protease inhibitors should not be administered concomitantly with<br />
nevirapine.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NIACIN</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Lovastatin and niacin used together may cause severe myopathy and<br />
rhabdomyolysis. Although this reaction has not been reported with concomitant use of<br />
pravastatin and niacin, patients should be instructed to report symptoms of muscle pain,<br />
weakness, or tenderness. If creatine kinase is elevated, the drugs should be<br />
discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMINOGLYCOSIDES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Aminoglycoside antibiotics may potentiate the neuromuscular blockade<br />
caused by non-depolarizing muscle relaxants. The mechanism is presynaptic acetylcholine<br />
release and reduction of postsynaptic sensitivity to acetylcholine. These combinations<br />
should be avoided if possible.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">POLYMYXIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Polymyxin B may prolong apnea and respiratory paralysis after use of<br />
neuromuscular blocking agents. The mechanism may be related to decreased intracellular<br />
potassium or decreased ionized serum calcium. Intravenous calcium administration may be<br />
helpful in reversing the paralysis.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">There may be an increased risk of CNS or respiratory depression when<br />
this combination of drugs is used.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Phenytoin may significantly reduce cyclosporine serum concentrations.<br />
The mechanism may be inhibition of cyclosporine absorption or induction of hepatic<br />
metabolism or both. This interaction may occur with ethotoin, fosphenytoin, and<br />
mephenytoin as well. Cyclosporine levels should be closely monitored during concomitant<br />
therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Dilantin can accelerate the metabolism of ritonavir thus reducing its<br />
plasma concentration. Ritonavir can raise or lower dilantin levels. Use caution if these<br />
drugs must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">K-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of potassium-sparing diuretics and potassium<br />
preparations may result in hyperkalemia. These agents should not be used together unless<br />
the patient has documented hypokalemia while taking either agent alone. If this<br />
combination is used, the patient should be given dietary counseling and monitored very<br />
closely for hyperkalemia.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PROCAINAMIDE</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some beta-blockers may decrease the clearance and increase the serum<br />
level of procainamide. Data are available for metoprolol and propranolol<br />
only.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone can increase quinidine concentrations inducing prolongation<br />
of the QT interval. Quinidine dose may need to be reduced by 50% if amiodarone is<br />
added.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil may increase plasma quinidine concentrations. While these<br />
drugs can be given together safely, significant adverse side effects can occur,<br />
especially in patients with hypertrophic or dilated cardiomyopathies and in patients on<br />
higher doses of either drug. If these drugs must be given together, lower doses of<br />
quinidine are needed to achieve a given plasma concentration and clinical response.<br />
Clinical and electrocardiographic monitoring for quinidine toxicity (such as hypotension,<br />
arrhythmias, and AV block) is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may interfere with the metabolism of meperidine. Large<br />
increases in serum meperidine concentrations may result. The concomitant use of these<br />
agents is contraindicated by the manufacturer and should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir capsules and ritonavir oral solution contain alcohol, which<br />
may cause a reaction when this drug is used with disulfiram or metronidazole.<br />
Simultaneous use should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The plasma concentration of saquinavir mesylate (Invirase) is<br />
increased markedly (29-fold) by ritonavir. The safety of their concurrent use has not<br />
been established. The newer form of saquinavir (Fortovase) is more bioavailable.<br />
Therefore, this interaction is less relevant for saquinavir (Fortovase).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may cause large fluctuations in the serum concentrations of<br />
warfarin. If ritonavir and warfarin must be used together, frequent monitoring of the INR<br />
is strongly recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFADIAZINE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some sulfonamides inhibit the hepatic metabolism of phenytoin. Serum<br />
phenytoin levels and risk of toxicity may be increased. Data are available for<br />
sulfadiazine and sulfamethizole. Management consists of monitoring the patient for signs<br />
and symptoms of phenytoin toxicity, checking serum levels, and decreasing phenytoin<br />
dosage as necessary.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFAMETHOXAZOLE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sulfonamides increase the level of warfarin-(S) isomer by an unknown<br />
mechanism. Hypoprothrombinemic effect is enhanced. . Frequent monitoring of the INR is<br />
recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TACROLIMUS</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">In vitro and in vivo data suggest that erythromycin may inhibit the<br />
hepatic metabolism of tacrolimus. Data from two case reports suggest that concomitant use<br />
of erythromycin may result in elevated serum tacrolimus concentrations. If these drugs<br />
are used concomitantly, plasma tacrolimus concentrations should be carefully monitored,<br />
with reductions in dosage to prevent nephrotoxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">CIPROFLOXACIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ciprofloxacin can significantly reduce the clearance of theophylline<br />
by inhibition of hepatic metabolism. The interaction can result in theophylline toxicity,<br />
and may increase the risk of seizures, especially in the elderly. The patient should be<br />
monitored for theophylline toxicity and elevated serum levels while also taking<br />
ciprofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolides (erythromycin and troleandomycin) inhibit theophylline<br />
metabolism. During coadministration, serum theophylline levels and risk of theophylline<br />
toxicity are increased. Conversely, theophylline increases the renal clearance of<br />
erythromycin and decreases erythromycin concentrations. Monitoring of theophylline levels<br />
and efficacy is recommended when erythromycin is added to or discontinued from the<br />
patient's regimen. [Dirithromycin [?on formulary]appears to increase the plasma clearance<br />
of theophylline, and plasma theophylline concentrations can be decreased by approximately<br />
26%. The dirithromycin-theophylline interaction is unlikely to be clinically significant<br />
enough to modify treatment and outcome.] The effects of azithromycin and clarithromycin<br />
on the pharmacokinetic disposition of theophylline are not known. Azithromycin, however,<br />
does not appear to interfere with theophylline levels and may be the macrolide of choice<br />
for patients on theophylline therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with phenytoin may cause a 25% increase in<br />
phenytoin plasma concentration, particularly in patients receiving phenytoin twice a day.<br />
Additionally, the concentration of topiramate decreased by 48%. Addition or withdrawal of<br />
hydantoins during therapy with topiramate may require a dose adjustment of topiramate<br />
and/or the hydantoin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">VALPROATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with valproic acid may lead to an 11% decrease<br />
in valproic acid plasma concentration. Additionally, the concentration of topiramate<br />
decreased by 14%. The mechanism of action may be increased metabolism of both drugs.<br />
Addition or withdrawal of valproic acid during adjunctive therapy with topiramate may<br />
require a dose adjustment of topiramate and/or valproic acid.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE<br><br />
KETOCONAZOLE<br><br />
FLUCONAZOLE<br><br />
MICONAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">These drugs may increase the effect of warfarin. The mechanism is<br />
unknown. Close monitoring of the INR is recommended if these drugs must be used<br />
together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">CELECOXIB<br><br />
ROFECOXIB</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Risk of bleeding is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may inhibit the hepatic metabolism of<br />
warfarin resulting in an enhanced anticoagulant effect. Data are available for<br />
erythromycin and clarithromycin only. Close monitoring of the INR is recommended if a<br />
macrolide antimicrobial and warfarin must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Metronidazole may inhibit the metabolism of warfarin and increase its<br />
anticoagulant effect. The INR should be monitored closely.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Warfarin can increase phenytoin half-life and serum concentrations.<br />
The addition of phenytoin to warfarin therapy can increase the INR. The mechanism is not<br />
known. Serum phenytoin concentrations and INR should be monitored in patients receiving<br />
this combination.</font></td><br />
</tr><br />
<br />
<tr align="left"><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINOLONES*<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Most fluoroquinolones can inhibit the metabolism of warfarin<br />
increasing the INR. Patients on concomitant therapy should be monitored for elevations in<br />
INR. However, one study of sixteen volunteers reported a lack of interaction between<br />
warfarin and levofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine can induce hypoprothrombinemia, thus raising the INR and<br />
increasing the risk of bleeding.<br />
</td></tr></table></div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug-Drug_Interaction_RulesDrug-Drug Interaction Rules2008-02-20T20:25:34Z<p>AdamWright: </p>
<hr />
<div><table border="1" cellpadding="1" cellspacing="2"><br />
<tr><br />
<td><font size="2"><b>Generic Drug Name or Category</b></font></td><br />
<br />
<td><font size="2"><b>Interacts With</font></b></td><br />
<br />
<td><font size="2"><b>Severity</font></b></td><br />
<br />
<td><font size="2"><b>Text</font></b></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">K-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Diuretics and ACE inhibitors used together may cause hypotension. The<br />
combination of ACE inhibitors and potassium-sparing diuretics may cause significant<br />
hyperkalemia. This effect is particularly significant in patients with renal<br />
insufficiency.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *</font></td><br />
<br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">ACE inhibitors may decrease aldosterone causing hyperkalemia. When ACE<br />
inhibitors are coadministered with potassium-containing products, the risk of<br />
hyperkalemia is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">AZATHIOPRINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Allopurinol inhibits the metabolism of oral azathioprine, increasing<br />
serum azathioprine levels. Concomitant use can cause marked bone marrow suppression. If<br />
these drugs must be used together, azathioprine oral doses should be reduced to 25-30% of<br />
the usual dosage and the patient should be monitored closely for toxicity. Intravenous<br />
azathioprine does not appear to be affected by allopurinol.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Concurrent use of allopurinol and theophylline may result in<br />
theophylline toxicity (nausea, vomiting, palpitations, seizures). This interaction is<br />
more likely to occur with daily allopurinol doses of 600 mg or more.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Reports suggest that amiodarone may interfere with the clearance of<br />
cyclosporine. The risk of cyclosporine toxicity may increase.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may increase serum digoxin concentrations by up to 100%.<br />
Amiodarone may increase intestinal transit time, reduce renal clearance of digoxin,<br />
inhibit hepatic metabolism of digoxin, displace digoxin from protein-binding sites, and,<br />
in some cases, induce hypothyroidism. Empirical reduction or discontinuation of digoxin<br />
should be considered. Management also consists of monitoring clinical response or<br />
checking serum digoxin levels if toxicity is suspected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may inhibit hepatic metabolism of warfarin. A 30% to 50%<br />
reduction in warfarin dosage is recommended, as is frequent monitoring of<br />
INR.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some azoles, particulary Ketoconazole and Itraconazole, may inhibit<br />
the hepatic metabolism of cyclosporine. Serum cyclosporine concentrations and<br />
nephrotoxicity may increase fourfold. Cyclosporine dosage reductions of 80% have been<br />
necessary in some patients.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The use of HMG-CoA reductase inhibitors during azole therapy may<br />
increase CK, AST, ALT, and LDH serum levels.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">BETA BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of these drugs may cause severe bradycardia, cardiac<br />
arrest, or ventricular fibrillation. Use extreme caution using these drugs<br />
together.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL *</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The concomitant use of calcium channel blockers and beta-blockers can<br />
occasionally cause AV heart block and left-ventricular dysfunction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase levels of calcium channel<br />
blockers. Be careful using this combination of drugs, and monitor for<br />
toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CIMETIDINE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Cimetidine inhibits the hepatic metabolism of warfarin, and may<br />
increase its anticoagulant effect over a one to two week period. If given together, the<br />
INR should be monitored, and the lowest possible dose of cimetidine should be used.<br />
Another histamine-2 antagonist may be used with less risk of interaction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CLOPIDOGREL BISULFATE</font></td><br />
<br />
<td><font size="2">NSAIDs *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The coadministration of nonsteroidal antiinflammatory drugs (NSAIDs)<br />
and clopidogrel should be undertaken with extreme caution. The coadministration of<br />
clopidogrel with naproxen resulted in occult gastrointestinal blood loss in healthy<br />
volunteers. The mechanism may be due to additive platelet inhibition. Additionally,<br />
diclofenac, ibuprofen, naproxen, mefenamic acid, indomethacin and piroxicam are<br />
substrates for the cytochrome P450 isoenzyme 2C9 inhibited by clopidogrel. The clinical<br />
magnitude of this interaction is not known. The clinician should observe the patient for<br />
increased NSAID toxicity if these agents are co-administered with<br />
clopidogrel.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may significantly increase cyclosporine<br />
serum concentrations, possibly by inhibiting hepatic metabolism of cyclosporine,<br />
resulting in nephrotoxicity. Appropriate monitoring of cyclosporine serum concentrations<br />
during co-administration is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">FOSCARNET SODIUM</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Foscarnet and cyclosporine used together may increase the risk of<br />
nephrotoxicity and renal failure. If these agents are used concomitantly, consider close<br />
observation of renal function and discontinue foscarnet if needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with high doses of Gemfibrozil can<br />
cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with moderate to high doses of HMG CoA<br />
reductase inhibitors can cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL<br><br />
DILTIAZEM</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil and Diltiazem may inhibit the hepatic metabolism of<br />
cyclosporine causing increased trough and steady state levels, and the risk of<br />
nephrotoxicity. Cyclosporine levels should be monitored, and dosage should be adjusted as<br />
needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DAPSONE</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Saquinavir may competitively inhibit the metabolism of drugs that are<br />
substrates of the cytochrome P-450 (3A4) microsomal enzymatic pathway. Plasma levels of<br />
these drugs may be elevated. The patient should be monitored closely for toxicities and<br />
lower dosages of these drugs may be necessary</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Theoretically this interaction might occur with other macrolides.<br />
Patients should be closely monitored for evidence of digoxin toxicity if macrolide<br />
antibiotics and digoxin must be coadministered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The addition of itraconazole to patients stabilized on digoxin has<br />
resulted in two to fourfold increases in serum digoxin concentrations and digoxin<br />
toxicity. The mechanism is unknown. The onset of toxicity generally occurs within 9 to 13<br />
days after the start of itraconazole therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">QUINIDINE<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine significantly increases serum digoxin levels in more than<br />
90% of patients. The mechanism is related to reduced renal and biliary clearance, and<br />
reduced volume of digoxin distribution. Empiric reduction in digoxin dosing may be<br />
considered at the initiation of combination therapy. Modifications in dosage should be<br />
expected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">TETRACYCLINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Tetracyclines may increase serum levels of orally administered digoxin<br />
in about 10% of the population. The mechanism may be related to changes in intestinal<br />
flora that alter the absorption of digoxin. If these drugs must be used together, the<br />
patient should be closely monitored for digoxin toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil increases digoxin levels significantly in most patients.<br />
This important and possibly severe interaction is related to several complex mechanisms.<br />
Digoxin and verapamil have additive effects in slowing AV conduction. Verapamil also<br />
decreases the elimination of digoxin. If verapamil and digoxin are used together to<br />
control a supraventricular tachyarrhythmia, the dosage of each drug may have to be<br />
reduced.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">CLARITHROMYCIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Efavirenz increases the metabolism of clarithromycin. No dosage<br />
adjustment is recommended when these drugs are co-administered, but a rash occurs in 46%<br />
of patients administered clarithromycin and efavirenz concomitantly. Alternative therapy<br />
such as azithromycin might be considered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">INDINAVIR SULFATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Coadministration of efavirenz and indinavir causes a decreased<br />
indinavir level. The mechanism of this interaction is hepatic enzyme induction of CYP3A4<br />
by efavirenz. The dosage of indinavir should be increased from 800 mg every 8 hours to<br />
1000 mg every 8 hours when these drugs are administered concomitantly.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ENOXAPARIN<br><br />
DALTEPARIN<br><br />
TINZAPARIN</font></td><br />
<br />
<td><font size="2">HEPARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Dalteparin may increase the risk of bleeding from heparin. The<br />
mechanism is additive inhibition of thrombin and factor Xa. If these agents must be used<br />
together, extreme caution is advised, and the patient should be monitored for signs of<br />
bleeding. Other low-molecular-weight heparins (LMWHs) may interact with heparin in a<br />
similar manner.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">KETOROLAC</font></td><br />
<br />
<td><font size="2">NSAIDs *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ketorolac is contraindicated in patients concurrently receiving<br />
aspirin or NSAIDs because of the cumulative risks of inducing serious NSAID-related<br />
adverse events (peptic ulcers, gastrointestinal bleeding and/or perforation).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">When lovastatin and some macrolide antibiotics (erythromycin) have<br />
been used concomitantly in severely ill patients, severe myopathy and rhabdomyolysis have<br />
resulted. The mechanism appears to be inhibition of lovastatin metabolism by the<br />
macrolide. Patients should be instructed to report symptoms of muscle pain, weakness, or<br />
tenderness. If symptoms occur, creatine kinase should be measured. If creatine kinase is<br />
elevated, the drugs should be discontinued. A similar reaction may occur with other<br />
HMG-CoA reductase inhibitors.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">FENTANYL</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase fentanyl plasma levels. Patients<br />
should be closely observed for toxicity if these drugs are used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Gemfibrozil and lovastatin used together can cause severe myopathy and<br />
rhabdomyolysis. Combined use of gemfibrozil or clofibrate with other HMG-CoA reductase<br />
inhibitors may increase the risk of this side effect as well. If this combination must be<br />
used, the patient should be instructed to report symptoms of muscular pain, weakness, or<br />
tenderness. If creatine kinase is elevated, the drugs should be discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Immediate onset of excitement, sweating, rigidity, and hypertension<br />
can occur when monoamine oxidase inhibitors (MAOIs) are used concurrently with<br />
meperidine. Death has been reported. Similar effects have been reported with propoxyphene<br />
and fentanyl, but not with other analgesics. The combination of narcotic analgesics and<br />
MAOIs should be avoided if possible. An MAOI plus meperidine should not be used under any<br />
circumstances.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">COMT INHIBITORS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) stop the catalyst enzyme<br />
catechol-O-methyltransferase (COMT) from metabolizing levodopa to 3-O-methyldopa in the<br />
periphery, and in the brain.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SSRI ANTIDEPRESSANTS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Severe and sometimes fatal reactions involving elevations in blood<br />
pressure, hyperthermia, rigidity, and autonomic instability have occurred in patients<br />
taking SSRIs in combination with monoamine oxidase inhibitors (MAOIs). A minimum period<br />
of two weeks should separate use of these drugs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SYMPATHOMIMETIC AGENTS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sympathomimetic amines used with monoamine oxidase inhibitors may<br />
precipitate severe hypertensive reactions</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">TRICYCLIC ANTIDEPRESSANTS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants<br />
when used together may cause hyperpyretic crises, disseminated intravascular coagulation,<br />
convulsions, and death. The mechanism is unknown. Although these agents have been used<br />
together safely in many patients, some investigators recommend that tricyclic<br />
antidepressants not be used within two weeks of MAOIs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">VENLAFAXINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) used together with<br />
anti-depressants may cause severe, even fatal, reactions. The reactions reported with the<br />
newer antidepressants include hyperthermia, rigidity, myoclonus, autonomic instability,<br />
and mental status changes that range from delirium to coma. In general, MAOIs and<br />
venlafaxine or other SSRIs should be separated by 2 weeks.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NARCOTICS *<br></font></td><br />
<br />
<td><font size="2">BENZODIAZEPINES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Narcotics and benzodiazepines used together can cause excessive<br />
respiratory and CNS depression. The mechanism may be related in part to inhibition of<br />
hepatic oxidation of the benzodiazepine. Alprazolam has been most implicated in this<br />
interaction. Such interactions are more likely to occur in the benzodiazepine and<br />
narcotic "naive" patient.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NEVIRAPINE</font></td><br />
<br />
<td><font size="2">PROTEASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Because nevirapine may induce the hepatic P450 cytochrome system,<br />
reductions in plasma concentrations of protease inhibitors theoretically may occur. The<br />
manufacturer recommends that, until clinical studies provide information on dosage<br />
adjustments, protease inhibitors should not be administered concomitantly with<br />
nevirapine.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NIACIN</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Lovastatin and niacin used together may cause severe myopathy and<br />
rhabdomyolysis. Although this reaction has not been reported with concomitant use of<br />
pravastatin and niacin, patients should be instructed to report symptoms of muscle pain,<br />
weakness, or tenderness. If creatine kinase is elevated, the drugs should be<br />
discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMINOGLYCOSIDES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Aminoglycoside antibiotics may potentiate the neuromuscular blockade<br />
caused by non-depolarizing muscle relaxants. The mechanism is presynaptic acetylcholine<br />
release and reduction of postsynaptic sensitivity to acetylcholine. These combinations<br />
should be avoided if possible.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">POLYMYXIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Polymyxin B may prolong apnea and respiratory paralysis after use of<br />
neuromuscular blocking agents. The mechanism may be related to decreased intracellular<br />
potassium or decreased ionized serum calcium. Intravenous calcium administration may be<br />
helpful in reversing the paralysis.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">There may be an increased risk of CNS or respiratory depression when<br />
this combination of drugs is used.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Phenytoin may significantly reduce cyclosporine serum concentrations.<br />
The mechanism may be inhibition of cyclosporine absorption or induction of hepatic<br />
metabolism or both. This interaction may occur with ethotoin, fosphenytoin, and<br />
mephenytoin as well. Cyclosporine levels should be closely monitored during concomitant<br />
therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Dilantin can accelerate the metabolism of ritonavir thus reducing its<br />
plasma concentration. Ritonavir can raise or lower dilantin levels. Use caution if these<br />
drugs must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">K-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of potassium-sparing diuretics and potassium<br />
preparations may result in hyperkalemia. These agents should not be used together unless<br />
the patient has documented hypokalemia while taking either agent alone. If this<br />
combination is used, the patient should be given dietary counseling and monitored very<br />
closely for hyperkalemia.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PROCAINAMIDE</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some beta-blockers may decrease the clearance and increase the serum<br />
level of procainamide. Data are available for metoprolol and propranolol<br />
only.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone can increase quinidine concentrations inducing prolongation<br />
of the QT interval. Quinidine dose may need to be reduced by 50% if amiodarone is<br />
added.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil may increase plasma quinidine concentrations. While these<br />
drugs can be given together safely, significant adverse side effects can occur,<br />
especially in patients with hypertrophic or dilated cardiomyopathies and in patients on<br />
higher doses of either drug. If these drugs must be given together, lower doses of<br />
quinidine are needed to achieve a given plasma concentration and clinical response.<br />
Clinical and electrocardiographic monitoring for quinidine toxicity (such as hypotension,<br />
arrhythmias, and AV block) is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may interfere with the metabolism of meperidine. Large<br />
increases in serum meperidine concentrations may result. The concomitant use of these<br />
agents is contraindicated by the manufacturer and should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir capsules and ritonavir oral solution contain alcohol, which<br />
may cause a reaction when this drug is used with disulfiram or metronidazole.<br />
Simultaneous use should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The plasma concentration of saquinavir mesylate (Invirase) is<br />
increased markedly (29-fold) by ritonavir. The safety of their concurrent use has not<br />
been established. The newer form of saquinavir (Fortovase) is more bioavailable.<br />
Therefore, this interaction is less relevant for saquinavir (Fortovase).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may cause large fluctuations in the serum concentrations of<br />
warfarin. If ritonavir and warfarin must be used together, frequent monitoring of the INR<br />
is strongly recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFADIAZINE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some sulfonamides inhibit the hepatic metabolism of phenytoin. Serum<br />
phenytoin levels and risk of toxicity may be increased. Data are available for<br />
sulfadiazine and sulfamethizole. Management consists of monitoring the patient for signs<br />
and symptoms of phenytoin toxicity, checking serum levels, and decreasing phenytoin<br />
dosage as necessary.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFAMETHOXAZOLE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sulfonamides increase the level of warfarin-(S) isomer by an unknown<br />
mechanism. Hypoprothrombinemic effect is enhanced. . Frequent monitoring of the INR is<br />
recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TACROLIMUS</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">In vitro and in vivo data suggest that erythromycin may inhibit the<br />
hepatic metabolism of tacrolimus. Data from two case reports suggest that concomitant use<br />
of erythromycin may result in elevated serum tacrolimus concentrations. If these drugs<br />
are used concomitantly, plasma tacrolimus concentrations should be carefully monitored,<br />
with reductions in dosage to prevent nephrotoxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">CIPROFLOXACIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ciprofloxacin can significantly reduce the clearance of theophylline<br />
by inhibition of hepatic metabolism. The interaction can result in theophylline toxicity,<br />
and may increase the risk of seizures, especially in the elderly. The patient should be<br />
monitored for theophylline toxicity and elevated serum levels while also taking<br />
ciprofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolides (erythromycin and troleandomycin) inhibit theophylline<br />
metabolism. During coadministration, serum theophylline levels and risk of theophylline<br />
toxicity are increased. Conversely, theophylline increases the renal clearance of<br />
erythromycin and decreases erythromycin concentrations. Monitoring of theophylline levels<br />
and efficacy is recommended when erythromycin is added to or discontinued from the<br />
patient's regimen. [Dirithromycin [?on formulary]appears to increase the plasma clearance<br />
of theophylline, and plasma theophylline concentrations can be decreased by approximately<br />
26%. The dirithromycin-theophylline interaction is unlikely to be clinically significant<br />
enough to modify treatment and outcome.] The effects of azithromycin and clarithromycin<br />
on the pharmacokinetic disposition of theophylline are not known. Azithromycin, however,<br />
does not appear to interfere with theophylline levels and may be the macrolide of choice<br />
for patients on theophylline therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with phenytoin may cause a 25% increase in<br />
phenytoin plasma concentration, particularly in patients receiving phenytoin twice a day.<br />
Additionally, the concentration of topiramate decreased by 48%. Addition or withdrawal of<br />
hydantoins during therapy with topiramate may require a dose adjustment of topiramate<br />
and/or the hydantoin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">VALPROATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with valproic acid may lead to an 11% decrease<br />
in valproic acid plasma concentration. Additionally, the concentration of topiramate<br />
decreased by 14%. The mechanism of action may be increased metabolism of both drugs.<br />
Addition or withdrawal of valproic acid during adjunctive therapy with topiramate may<br />
require a dose adjustment of topiramate and/or valproic acid.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE<br><br />
KETOCONAZOLE<br><br />
FLUCONAZOLE<br><br />
MICONAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">These drugs may increase the effect of warfarin. The mechanism is<br />
unknown. Close monitoring of the INR is recommended if these drugs must be used<br />
together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">CELECOXIB<br><br />
ROFECOXIB</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Risk of bleeding is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may inhibit the hepatic metabolism of<br />
warfarin resulting in an enhanced anticoagulant effect. Data are available for<br />
erythromycin and clarithromycin only. Close monitoring of the INR is recommended if a<br />
macrolide antimicrobial and warfarin must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Metronidazole may inhibit the metabolism of warfarin and increase its<br />
anticoagulant effect. The INR should be monitored closely.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Warfarin can increase phenytoin half-life and serum concentrations.<br />
The addition of phenytoin to warfarin therapy can increase the INR. The mechanism is not<br />
known. Serum phenytoin concentrations and INR should be monitored in patients receiving<br />
this combination.</font></td><br />
</tr><br />
<br />
<tr align="left"><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINOLONES*<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Most fluoroquinolones can inhibit the metabolism of warfarin<br />
increasing the INR. Patients on concomitant therapy should be monitored for elevations in<br />
INR. However, one study of sixteen volunteers reported a lack of interaction between<br />
warfarin and levofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine can induce hypoprothrombinemia, thus raising the INR and<br />
increasing the risk of bleeding.</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Drug-Drug_Interaction_RulesDrug-Drug Interaction Rules2008-02-20T20:24:35Z<p>AdamWright: </p>
<hr />
<div><table border="1" cellpadding="1" cellspacing="2"><br />
<tr><br />
<td><font size="2"><b>Generic Drug Name or Category</b></font></td><br />
<br />
<td><font size="2"><b>Interacts With</font></b></td><br />
<br />
<td><font size="2"><b>Severity</font></b></td><br />
<br />
<td><font size="2"><b>Text</font></b></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">K-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Diuretics and ACE inhibitors used together may cause hypotension. The<br />
combination of ACE inhibitors and potassium-sparing diuretics may cause significant<br />
hyperkalemia. This effect is particularly significant in patients with renal<br />
insufficiency.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ACE INHIBITORS *</font></td><br />
<br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">ACE inhibitors may decrease aldosterone causing hyperkalemia. When ACE<br />
inhibitors are coadministered with potassium-containing products, the risk of<br />
hyperkalemia is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">AZATHIOPRINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Allopurinol inhibits the metabolism of oral azathioprine, increasing<br />
serum azathioprine levels. Concomitant use can cause marked bone marrow suppression. If<br />
these drugs must be used together, azathioprine oral doses should be reduced to 25-30% of<br />
the usual dosage and the patient should be monitored closely for toxicity. Intravenous<br />
azathioprine does not appear to be affected by allopurinol.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ALLOPURINOL</font></td><br />
<br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Concurrent use of allopurinol and theophylline may result in<br />
theophylline toxicity (nausea, vomiting, palpitations, seizures). This interaction is<br />
more likely to occur with daily allopurinol doses of 600 mg or more.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Reports suggest that amiodarone may interfere with the clearance of<br />
cyclosporine. The risk of cyclosporine toxicity may increase.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may increase serum digoxin concentrations by up to 100%.<br />
Amiodarone may increase intestinal transit time, reduce renal clearance of digoxin,<br />
inhibit hepatic metabolism of digoxin, displace digoxin from protein-binding sites, and,<br />
in some cases, induce hypothyroidism. Empirical reduction or discontinuation of digoxin<br />
should be considered. Management also consists of monitoring clinical response or<br />
checking serum digoxin levels if toxicity is suspected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone may inhibit hepatic metabolism of warfarin. A 30% to 50%<br />
reduction in warfarin dosage is recommended, as is frequent monitoring of<br />
INR.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some azoles, particulary Ketoconazole and Itraconazole, may inhibit<br />
the hepatic metabolism of cyclosporine. Serum cyclosporine concentrations and<br />
nephrotoxicity may increase fourfold. Cyclosporine dosage reductions of 80% have been<br />
necessary in some patients.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">AZOLE ANTIFUNGALS *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The use of HMG-CoA reductase inhibitors during azole therapy may<br />
increase CK, AST, ALT, and LDH serum levels.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">BETA BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of these drugs may cause severe bradycardia, cardiac<br />
arrest, or ventricular fibrillation. Use extreme caution using these drugs<br />
together.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL *</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The concomitant use of calcium channel blockers and beta-blockers can<br />
occasionally cause AV heart block and left-ventricular dysfunction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CALCIUM CHANNEL BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase levels of calcium channel<br />
blockers. Be careful using this combination of drugs, and monitor for<br />
toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CIMETIDINE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Cimetidine inhibits the hepatic metabolism of warfarin, and may<br />
increase its anticoagulant effect over a one to two week period. If given together, the<br />
INR should be monitored, and the lowest possible dose of cimetidine should be used.<br />
Another histamine-2 antagonist may be used with less risk of interaction.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CLOPIDOGREL BISULFATE</font></td><br />
<br />
<td><font size="2">NSAIDs *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The coadministration of nonsteroidal antiinflammatory drugs (NSAIDs)<br />
and clopidogrel should be undertaken with extreme caution. The coadministration of<br />
clopidogrel with naproxen resulted in occult gastrointestinal blood loss in healthy<br />
volunteers. The mechanism may be due to additive platelet inhibition. Additionally,<br />
diclofenac, ibuprofen, naproxen, mefenamic acid, indomethacin and piroxicam are<br />
substrates for the cytochrome P450 isoenzyme 2C9 inhibited by clopidogrel. The clinical<br />
magnitude of this interaction is not known. The clinician should observe the patient for<br />
increased NSAID toxicity if these agents are co-administered with<br />
clopidogrel.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may significantly increase cyclosporine<br />
serum concentrations, possibly by inhibiting hepatic metabolism of cyclosporine,<br />
resulting in nephrotoxicity. Appropriate monitoring of cyclosporine serum concentrations<br />
during co-administration is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">FOSCARNET SODIUM</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Foscarnet and cyclosporine used together may increase the risk of<br />
nephrotoxicity and renal failure. If these agents are used concomitantly, consider close<br />
observation of renal function and discontinue foscarnet if needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with high doses of Gemfibrozil can<br />
cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Cyclosporine used concurrently with moderate to high doses of HMG CoA<br />
reductase inhibitors can cause rhabdomyolysis.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL<br><br />
DILTIAZEM</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil and Diltiazem may inhibit the hepatic metabolism of<br />
cyclosporine causing increased trough and steady state levels, and the risk of<br />
nephrotoxicity. Cyclosporine levels should be monitored, and dosage should be adjusted as<br />
needed.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DAPSONE</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Saquinavir may competitively inhibit the metabolism of drugs that are<br />
substrates of the cytochrome P-450 (3A4) microsomal enzymatic pathway. Plasma levels of<br />
these drugs may be elevated. The patient should be monitored closely for toxicities and<br />
lower dosages of these drugs may be necessary</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Theoretically this interaction might occur with other macrolides.<br />
Patients should be closely monitored for evidence of digoxin toxicity if macrolide<br />
antibiotics and digoxin must be coadministered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The addition of itraconazole to patients stabilized on digoxin has<br />
resulted in two to fourfold increases in serum digoxin concentrations and digoxin<br />
toxicity. The mechanism is unknown. The onset of toxicity generally occurs within 9 to 13<br />
days after the start of itraconazole therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">QUINIDINE<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine significantly increases serum digoxin levels in more than<br />
90% of patients. The mechanism is related to reduced renal and biliary clearance, and<br />
reduced volume of digoxin distribution. Empiric reduction in digoxin dosing may be<br />
considered at the initiation of combination therapy. Modifications in dosage should be<br />
expected.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">TETRACYCLINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Tetracyclines may increase serum levels of orally administered digoxin<br />
in about 10% of the population. The mechanism may be related to changes in intestinal<br />
flora that alter the absorption of digoxin. If these drugs must be used together, the<br />
patient should be closely monitored for digoxin toxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">DIGOXIN</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil increases digoxin levels significantly in most patients.<br />
This important and possibly severe interaction is related to several complex mechanisms.<br />
Digoxin and verapamil have additive effects in slowing AV conduction. Verapamil also<br />
decreases the elimination of digoxin. If verapamil and digoxin are used together to<br />
control a supraventricular tachyarrhythmia, the dosage of each drug may have to be<br />
reduced.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">CLARITHROMYCIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Efavirenz increases the metabolism of clarithromycin. No dosage<br />
adjustment is recommended when these drugs are co-administered, but a rash occurs in 46%<br />
of patients administered clarithromycin and efavirenz concomitantly. Alternative therapy<br />
such as azithromycin might be considered.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">EFAVIRENZ</font></td><br />
<br />
<td><font size="2">INDINAVIR SULFATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Coadministration of efavirenz and indinavir causes a decreased<br />
indinavir level. The mechanism of this interaction is hepatic enzyme induction of CYP3A4<br />
by efavirenz. The dosage of indinavir should be increased from 800 mg every 8 hours to<br />
1000 mg every 8 hours when these drugs are administered concomitantly.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">ENOXAPARIN<br><br />
DALTEPARIN<br><br />
TINZAPARIN</font></td><br />
<br />
<td><font size="2">HEPARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Dalteparin may increase the risk of bleeding from heparin. The<br />
mechanism is additive inhibition of thrombin and factor Xa. If these agents must be used<br />
together, extreme caution is advised, and the patient should be monitored for signs of<br />
bleeding. Other low-molecular-weight heparins (LMWHs) may interact with heparin in a<br />
similar manner.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">KETOROLAC</font></td><br />
<br />
<td><font size="2">NSAIDs *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ketorolac is contraindicated in patients concurrently receiving<br />
aspirin or NSAIDs because of the cumulative risks of inducing serious NSAID-related<br />
adverse events (peptic ulcers, gastrointestinal bleeding and/or perforation).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">When lovastatin and some macrolide antibiotics (erythromycin) have<br />
been used concomitantly in severely ill patients, severe myopathy and rhabdomyolysis have<br />
resulted. The mechanism appears to be inhibition of lovastatin metabolism by the<br />
macrolide. Patients should be instructed to report symptoms of muscle pain, weakness, or<br />
tenderness. If symptoms occur, creatine kinase should be measured. If creatine kinase is<br />
elevated, the drugs should be discontinued. A similar reaction may occur with other<br />
HMG-CoA reductase inhibitors.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">FENTANYL</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may significantly increase fentanyl plasma levels. Patients<br />
should be closely observed for toxicity if these drugs are used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">GEMFIBROZIL</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Gemfibrozil and lovastatin used together can cause severe myopathy and<br />
rhabdomyolysis. Combined use of gemfibrozil or clofibrate with other HMG-CoA reductase<br />
inhibitors may increase the risk of this side effect as well. If this combination must be<br />
used, the patient should be instructed to report symptoms of muscular pain, weakness, or<br />
tenderness. If creatine kinase is elevated, the drugs should be discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Immediate onset of excitement, sweating, rigidity, and hypertension<br />
can occur when monoamine oxidase inhibitors (MAOIs) are used concurrently with<br />
meperidine. Death has been reported. Similar effects have been reported with propoxyphene<br />
and fentanyl, but not with other analgesics. The combination of narcotic analgesics and<br />
MAOIs should be avoided if possible. An MAOI plus meperidine should not be used under any<br />
circumstances.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">COMT INHIBITORS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) stop the catalyst enzyme<br />
catechol-O-methyltransferase (COMT) from metabolizing levodopa to 3-O-methyldopa in the<br />
periphery, and in the brain.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SSRI ANTIDEPRESSANTS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Severe and sometimes fatal reactions involving elevations in blood<br />
pressure, hyperthermia, rigidity, and autonomic instability have occurred in patients<br />
taking SSRIs in combination with monoamine oxidase inhibitors (MAOIs). A minimum period<br />
of two weeks should separate use of these drugs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">SYMPATHOMIMETIC AGENTS<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sympathomimetic amines used with monoamine oxidase inhibitors may<br />
precipitate severe hypertensive reactions</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">TRICYCLIC ANTIDEPRESSANTS *</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants<br />
when used together may cause hyperpyretic crises, disseminated intravascular coagulation,<br />
convulsions, and death. The mechanism is unknown. Although these agents have been used<br />
together safely in many patients, some investigators recommend that tricyclic<br />
antidepressants not be used within two weeks of MAOIs.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">MAO INHIBITORS *</font></td><br />
<br />
<td><font size="2">VENLAFAXINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Monoamine oxidase inhibitors (MAOIs) used together with<br />
anti-depressants may cause severe, even fatal, reactions. The reactions reported with the<br />
newer antidepressants include hyperthermia, rigidity, myoclonus, autonomic instability,<br />
and mental status changes that range from delirium to coma. In general, MAOIs and<br />
venlafaxine or other SSRIs should be separated by 2 weeks.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NARCOTICS *<br></font></td><br />
<br />
<td><font size="2">BENZODIAZEPINES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Narcotics and benzodiazepines used together can cause excessive<br />
respiratory and CNS depression. The mechanism may be related in part to inhibition of<br />
hepatic oxidation of the benzodiazepine. Alprazolam has been most implicated in this<br />
interaction. Such interactions are more likely to occur in the benzodiazepine and<br />
narcotic "naive" patient.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NEVIRAPINE</font></td><br />
<br />
<td><font size="2">PROTEASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Because nevirapine may induce the hepatic P450 cytochrome system,<br />
reductions in plasma concentrations of protease inhibitors theoretically may occur. The<br />
manufacturer recommends that, until clinical studies provide information on dosage<br />
adjustments, protease inhibitors should not be administered concomitantly with<br />
nevirapine.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NIACIN</font></td><br />
<br />
<td><font size="2">HMG COA REDUCTASE INHIBITORS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Lovastatin and niacin used together may cause severe myopathy and<br />
rhabdomyolysis. Although this reaction has not been reported with concomitant use of<br />
pravastatin and niacin, patients should be instructed to report symptoms of muscle pain,<br />
weakness, or tenderness. If creatine kinase is elevated, the drugs should be<br />
discontinued.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *</font></td><br />
<br />
<td><font size="2">AMINOGLYCOSIDES *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Aminoglycoside antibiotics may potentiate the neuromuscular blockade<br />
caused by non-depolarizing muscle relaxants. The mechanism is presynaptic acetylcholine<br />
release and reduction of postsynaptic sensitivity to acetylcholine. These combinations<br />
should be avoided if possible.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">NM BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">POLYMYXIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Polymyxin B may prolong apnea and respiratory paralysis after use of<br />
neuromuscular blocking agents. The mechanism may be related to decreased intracellular<br />
potassium or decreased ionized serum calcium. Intravenous calcium administration may be<br />
helpful in reversing the paralysis.<br></font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS *<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">There may be an increased risk of CNS or respiratory depression when<br />
this combination of drugs is used.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">CYCLOSPORINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Phenytoin may significantly reduce cyclosporine serum concentrations.<br />
The mechanism may be inhibition of cyclosporine absorption or induction of hepatic<br />
metabolism or both. This interaction may occur with ethotoin, fosphenytoin, and<br />
mephenytoin as well. Cyclosporine levels should be closely monitored during concomitant<br />
therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Dilantin can accelerate the metabolism of ritonavir thus reducing its<br />
plasma concentration. Ritonavir can raise or lower dilantin levels. Use caution if these<br />
drugs must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">POTASSIUM *</font></td><br />
<br />
<td><font size="2">K-SPARING DIURETICS *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">The combination of potassium-sparing diuretics and potassium<br />
preparations may result in hyperkalemia. These agents should not be used together unless<br />
the patient has documented hypokalemia while taking either agent alone. If this<br />
combination is used, the patient should be given dietary counseling and monitored very<br />
closely for hyperkalemia.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">PROCAINAMIDE</font></td><br />
<br />
<td><font size="2">BETA BLOCKERS</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Some beta-blockers may decrease the clearance and increase the serum<br />
level of procainamide. Data are available for metoprolol and propranolol<br />
only.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">AMIODARONE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Amiodarone can increase quinidine concentrations inducing prolongation<br />
of the QT interval. Quinidine dose may need to be reduced by 50% if amiodarone is<br />
added.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">VERAPAMIL</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Verapamil may increase plasma quinidine concentrations. While these<br />
drugs can be given together safely, significant adverse side effects can occur,<br />
especially in patients with hypertrophic or dilated cardiomyopathies and in patients on<br />
higher doses of either drug. If these drugs must be given together, lower doses of<br />
quinidine are needed to achieve a given plasma concentration and clinical response.<br />
Clinical and electrocardiographic monitoring for quinidine toxicity (such as hypotension,<br />
arrhythmias, and AV block) is recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">MEPERIDINE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir may interfere with the metabolism of meperidine. Large<br />
increases in serum meperidine concentrations may result. The concomitant use of these<br />
agents is contraindicated by the manufacturer and should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Ritonavir capsules and ritonavir oral solution contain alcohol, which<br />
may cause a reaction when this drug is used with disulfiram or metronidazole.<br />
Simultaneous use should be avoided.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">SAQUINAVIR</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">The plasma concentration of saquinavir mesylate (Invirase) is<br />
increased markedly (29-fold) by ritonavir. The safety of their concurrent use has not<br />
been established. The newer form of saquinavir (Fortovase) is more bioavailable.<br />
Therefore, this interaction is less relevant for saquinavir (Fortovase).</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">RITONAVIR</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ritonavir may cause large fluctuations in the serum concentrations of<br />
warfarin. If ritonavir and warfarin must be used together, frequent monitoring of the INR<br />
is strongly recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFADIAZINE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some sulfonamides inhibit the hepatic metabolism of phenytoin. Serum<br />
phenytoin levels and risk of toxicity may be increased. Data are available for<br />
sulfadiazine and sulfamethizole. Management consists of monitoring the patient for signs<br />
and symptoms of phenytoin toxicity, checking serum levels, and decreasing phenytoin<br />
dosage as necessary.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">SULFAMETHOXAZOLE</font></td><br />
<br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Sulfonamides increase the level of warfarin-(S) isomer by an unknown<br />
mechanism. Hypoprothrombinemic effect is enhanced. . Frequent monitoring of the INR is<br />
recommended.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TACROLIMUS</font></td><br />
<br />
<td><font size="2">MACROLIDES *</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">In vitro and in vivo data suggest that erythromycin may inhibit the<br />
hepatic metabolism of tacrolimus. Data from two case reports suggest that concomitant use<br />
of erythromycin may result in elevated serum tacrolimus concentrations. If these drugs<br />
are used concomitantly, plasma tacrolimus concentrations should be carefully monitored,<br />
with reductions in dosage to prevent nephrotoxicity.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">CIPROFLOXACIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Ciprofloxacin can significantly reduce the clearance of theophylline<br />
by inhibition of hepatic metabolism. The interaction can result in theophylline toxicity,<br />
and may increase the risk of seizures, especially in the elderly. The patient should be<br />
monitored for theophylline toxicity and elevated serum levels while also taking<br />
ciprofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">THEOPHYLLINE</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolides (erythromycin and troleandomycin) inhibit theophylline<br />
metabolism. During coadministration, serum theophylline levels and risk of theophylline<br />
toxicity are increased. Conversely, theophylline increases the renal clearance of<br />
erythromycin and decreases erythromycin concentrations. Monitoring of theophylline levels<br />
and efficacy is recommended when erythromycin is added to or discontinued from the<br />
patient's regimen. [Dirithromycin [?on formulary]appears to increase the plasma clearance<br />
of theophylline, and plasma theophylline concentrations can be decreased by approximately<br />
26%. The dirithromycin-theophylline interaction is unlikely to be clinically significant<br />
enough to modify treatment and outcome.] The effects of azithromycin and clarithromycin<br />
on the pharmacokinetic disposition of theophylline are not known. Azithromycin, however,<br />
does not appear to interfere with theophylline levels and may be the macrolide of choice<br />
for patients on theophylline therapy.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with phenytoin may cause a 25% increase in<br />
phenytoin plasma concentration, particularly in patients receiving phenytoin twice a day.<br />
Additionally, the concentration of topiramate decreased by 48%. Addition or withdrawal of<br />
hydantoins during therapy with topiramate may require a dose adjustment of topiramate<br />
and/or the hydantoin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">TOPIRAMATE</font></td><br />
<br />
<td><font size="2">VALPROATE</font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Topiramate administered with valproic acid may lead to an 11% decrease<br />
in valproic acid plasma concentration. Additionally, the concentration of topiramate<br />
decreased by 14%. The mechanism of action may be increased metabolism of both drugs.<br />
Addition or withdrawal of valproic acid during adjunctive therapy with topiramate may<br />
require a dose adjustment of topiramate and/or valproic acid.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">ITRACONAZOLE<br><br />
KETOCONAZOLE<br><br />
FLUCONAZOLE<br><br />
MICONAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">These drugs may increase the effect of warfarin. The mechanism is<br />
unknown. Close monitoring of the INR is recommended if these drugs must be used<br />
together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">CELECOXIB<br><br />
ROFECOXIB</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Risk of bleeding is increased.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">MACROLIDES *<br></font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Some macrolide antibiotics may inhibit the hepatic metabolism of<br />
warfarin resulting in an enhanced anticoagulant effect. Data are available for<br />
erythromycin and clarithromycin only. Close monitoring of the INR is recommended if a<br />
macrolide antimicrobial and warfarin must be used together.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">METRONIDAZOLE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Metronidazole may inhibit the metabolism of warfarin and increase its<br />
anticoagulant effect. The INR should be monitored closely.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">PHENYTOIN</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Warfarin can increase phenytoin half-life and serum concentrations.<br />
The addition of phenytoin to warfarin therapy can increase the INR. The mechanism is not<br />
known. Serum phenytoin concentrations and INR should be monitored in patients receiving<br />
this combination.</font></td><br />
</tr><br />
<br />
<tr align="left"><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINOLONES*<br></font></td><br />
<br />
<td><font size="2">Significant</font></td><br />
<br />
<td><font size="2">Most fluoroquinolones can inhibit the metabolism of warfarin<br />
increasing the INR. Patients on concomitant therapy should be monitored for elevations in<br />
INR. However, one study of sixteen volunteers reported a lack of interaction between<br />
warfarin and levofloxacin.</font></td><br />
</tr><br />
<br />
<tr><br />
<td><font size="2">WARFARIN</font></td><br />
<br />
<td><font size="2">QUINIDINE</font></td><br />
<br />
<td><font size="2">Critical</font></td><br />
<br />
<td><font size="2">Quinidine can induce hypoprothrombinemia, thus raising the INR and<br />
increasing the risk of bleeding.</font></td><br />
</tr><br />
</table></div>AdamWrighthttp://clinfowiki.org/wiki/index.php/CDSCDS2008-02-20T20:22:00Z<p>AdamWright: /* Sample Decision Support Content */</p>
<hr />
<div>==Clinical Decision Support -- CDS==<br />
<br />
===Overview===<br />
<br />
Clinical Decision Support (CDS) refers broadly to providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care. Clinical knowledge of interest could range from simple facts and relationships to best practices for managing patients with specific disease states, new medical knowledge from clinical research and other types of information.<br />
<br />
For an overview of the process that healthcare organizations can use to begin, or improve, a clinical decision support (CDS) initiative interested parties can follow the guidelines described in <br />
[http://www.himss.org/ASP/topics_cds_workbook.asp?faid=108&tid=14 Improving Outcomes with Clinical Decision Suppport: An Implementer's Guide] to measurably improve key healthcare outcomes such as the quality, safety, and cost-effectiveness of care delivery.<br />
<br />
*[[National Roadmap for Clinical Decision Support]]<br />
*[[History of decision support]]<br />
*[[General system features associated with improvements in clinical practice]]<br />
*[http://wellness.wikispaces.com/Tactic+-+Support+Decisions+with+Diagnostic+Aids Support Decisions with Diagnostic Aids]<br />
*[[Clinical Decision Support Liability]]<br />
<br />
===[[Modes of Interaction]]===<br />
*[[Interpretation]]<br />
*[[Consultation]]<br />
*[[Monitoring]]<br />
*[[Critiquing]]<br />
*[[Teaching]]<br />
<br />
===[[Order Sets]]===<br />
*[[Personal Order Sets]]<br />
*[[Functional Specifications]]<br />
*[[Criteria for creating new order sets]]<br />
*[[A Process for Creating and Maintaining Order Sets]]<br />
<br />
===[[Information Resources]]===<br />
*[[Alerts and Reminders]]<br />
*[[Alert Fatigue]]?<br />
*[[Alert placement in clinical workflow]]<br />
*[[Initial Selection of What to Alert on...]]<br />
<br />
===Examples available on the web===<br />
*[[GIDEON|GIDEON (Global Infectious Diseases and Epidemiology Network)]]<br />
*[[Isabel (diagnostic decision support system)]]<br />
[[:Category:CDS|All articles related to clinical decision support]]<br />
<br />
===Business Intelligence and Data Warehousing===<br />
*[[Business Intelligence & Data Warehousing for Healthcare]]<br />
*[[Clinical Data Warehousing]]<br />
<br />
===Medication-Based Safety Rules===<br />
*[[Potentially Inappropriate Medication (PIM) Use in Older Adults:65 years and older (Based on 2000 updated Beers Criteria)]]<br />
**[[List of some PIM use independent of patient conditions and diagnosis (drugs with ADE severity rating of HIGH only)]]<br />
**[[List of some PIM use for patient with specific conditions (drugs with ADE severity rating of HIGH only)]]<br />
*[[Medications to be avoided in the elderly]]<br />
*[[Medications requiring dosage adjustments in renal insufficiency]]<br />
*[[Common Corollary orders]]<br />
*[[Drug-Laboratory Interactions]]<br />
*[[Drug-Drug interaction]]<br />
*[[Drug-Allergy Interactions]]<br />
*[[Detection of Adverse Mediation-Related Events]]<br />
*[[Drug-Food Interactions]]<br />
*[[Drug-Tobacco Interactions]]<br />
*[[Medications requiring dosage adjustments in hepatic disease]]<br />
*[[Medications to be avoided during pregnancy]]<br />
*[[Medications to be avoided while breastfeeding]]<br />
*[[Vaccination contraindications]]<br />
<br />
===Non-Medication-Based Safety Rules===<br />
* [[Diagnosis-Order Rules]]<br />
<br />
===Validation and Verification of Clinical Decision Support===<br />
*[[On Validation and Verification Of Decision Support Protocol Subsystems During Implementation-Optimization: Encapsulating P(X)]]<br />
<br />
===Sample Decision Support Content===<br />
* [[Diabetes CDS Content]]<br />
* [[Drug-Drug Interaction Rules]]</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Diabetes_order_setsDiabetes order sets2007-09-11T18:58:30Z<p>AdamWright: </p>
<hr />
<div>These diabetes order sets are based on content released into the public domain by [[Kaiser Permanente]].<br />
<br />
Each order set contains a variety of common orders for patients with diabetes. One of the major questions in order set design is whether a good order set has all of the choices someone might want (which implies that an order set is a tool for making ordering quicker), or whether it should contain the "best" choices (which implies that an order set is a tool for influencing ordering behavior). These two order sets lean towards the side of inclusiveness, although they do make a careful effort to be evidence-based, and generally contain drugs available in a generic form in the United States.<br />
<br />
=== An order set for Type II Diabetes, with a focus on DM management ===<br />
* Diagnoses (with ICD-9 codes)<br />
*** DM 2 [250.00H]<br />
*** DM 2 W DIABETIC NEPHROPATHY<br />
*** DM 2 W DIABETIC PERIPHERAL NEUROPATHY<br />
* Medications<br />
*** SURESTEP TEST STRIPS (Sig: Use as directed for diabetes, Disp: 100)<br />
*** ONE TOUCH ULTRASOFT LANCETS (Sig: Use as directed, Disp: 100)<br />
*** ONE TOUCH ULTRA 2 KIT (Sig: Use as directed, Disp: 1)<br />
*** ONE TOUCH ULTRA TEST STRIPS (Sig: Use as directed, Disp: 100)<br />
*** ASPIRIN 81 MG ORAL EC TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR DIABETES HEART PROTECTION, Disp: 100)<br />
*** ASPIRIN 325 MG ORAL EC TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR DIABETES HEART PROTECTION, Disp: 100)<br />
*** METFORMIN 500 MG ORAL TAB (Sig: TAKE 1 TAB PO BID FOR DIABETES, Disp: 120)<br />
*** METFORMIN 1,000 MG ORAL TAB (Sig: TAKE 1 TAB PO BID FOR DIABETES, Disp: 120)<br />
*** GLIPIZIDE 5 MG ORAL TAB (Sig: TAKE 1 TAB PO ONE DAILY FOR DIABETES, Disp: 60)<br />
*** GLIPIZIDE 5 MG ORAL TAB (Sig: TAKE 1 TAB PO BID FOR DIABETES, Disp: 120)<br />
*** GLIPIZIDE 10 MG ORAL TAB (Sig: TAKE 1 TAB PO ONE DAILY FOR DIABETES, Disp: 60)<br />
*** GLIPIZIDE 10 MG ORAL TAB (Sig: TAKE 1 TAB PO BID FOR DIABETES, Disp: 120)<br />
*** GLIPIZIDE 10 MG ORAL TAB (Sig: TAKE 2 TABS PO BID FOR DIABETES, Disp: 240)<br />
*** SIMVASTATIN 10 MG ORAL TAB (Sig: take 1 tab po once daily for cholesterol, Disp: 60)<br />
*** SIMVASTATIN 20 MG ORAL TAB (Sig: take 1 tab po once daily for cholesterol, Disp: 60)<br />
*** SIMVASTATIN 40 MG ORAL TAB (Sig: take 1 tab po once daily for cholesterol, Disp: 60)<br />
*** SIMVASTATIN 80 MG ORAL TAB (Sig: take 1 tab po once daily for cholesterol, Disp: 60)<br />
*** LISINOPRIL 10 MG ORAL TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL 20 MG ORAL TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL 40 MG ORAL TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL-HYDROCHLOROTHIAZIDE 10 MG-12.5 MG TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL-HYDROCHLOROTHIAZIDE 20 MG-12.5 MG TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL-HYDROCHLOROTHIAZIDE 20 MG-25 MG TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** NPH INSULIN 100 UNIT/ML INJ (Sig: INJECT SUBCUTANEOUSLY AS DIRECTED FOR DIABETES, Disp: 20)<br />
*** REGULAR INSULIN 100 UNIT/ML INJ (Sig: INJECT SUBCUTANEOUSLY AS DIRECTED FOR DIABETES, Disp: 20)<br />
* Immunizations (with CPT codes)<br />
** Immunization<br />
*** TDaP Vaccination 0.5 ml IM (ages 11-64) [90715A]<br />
*** Td (adult) vaccination, 0.5 mL IM (age 65 and over) [90718C]<br />
*** Pneumococcal Polysaccharide (Pneumovax) vaccination, 0.5 mL IM [90732C]<br />
*** Influenza vaccination, 3 yr - adult, 0.5 mL IM [90658C]<br />
*** Influenza vaccination, 0.5 mL IntraNasal [90660C]<br />
** Administration Codes<br />
*** VACC ADMIN, FIRST IM OR SUBQ VACCINE TOXOID (Always order) [90471B] <br />
*** VACC ADMIN, EACH ADDITIONAL IM OR SUBQ VACCINE TOXOID (For 2 or more total IMM's select FIRST IMM code above, and this code for each additional administration) [90472B]<br />
*** VACC ADMIN, FIRST INTRANASAL OR PO VACCINE TOXOID [90473B]<br />
* Lab orders (with CPT codes)<br />
** Labs today<br />
*** CBC W DIFFERENTIAL, AUTO [85025B]<br />
*** POTASSIUM, SERUM [84132C]<br />
*** CREATININE, SERUM [82565C]<br />
*** GLUCOSE, FASTING [82947B]<br />
*** ELECTROLYTES, SERUM [80051E]<br />
*** TSH W REFLEX TO FT4 [84443K]<br />
*** TSH ONLY [84443B]<br />
*** LIPID PANEL, FASTING [80061B]<br />
*** LIPID PANEL, NON-FASTING [80061D]<br />
*** ALT, SERUM [84460B]<br />
*** PSA [84153B]<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** MICROALBUMIN/CREATININE, URINE [200479]<br />
** Labs today<br />
*** CBC W DIFFERENTIAL, AUTO [85025B]<br />
*** CREATININE, SERUM [82565C]<br />
*** GLUCOSE, FASTING [82947B]<br />
*** ELECTROLYTES, SERUM [80051E]<br />
*** TSH W REFLEX TO FT4 [84443K]<br />
*** TSH ONLY [84443B]<br />
*** LIPID PANEL, FASTING [80061B]<br />
*** LIPID PANEL, NON-FASTING [80061D]<br />
*** ALT, SERUM [84460B]<br />
*** PSA [84153B]<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** MICROALBUMIN/CREATININE, URINE [200479]<br />
** Labs in 3-12 months<br />
*** CBC W DIFFERENTIAL, AUTO [85025B]<br />
*** CREATININE, SERUM [82565C]<br />
*** GLUCOSE, FASTING [82947B]<br />
*** ELECTROLYTES, SERUM [80051E]<br />
*** TSH W REFLEX TO FT4 [84443K]<br />
*** TSH ONLY [84443B]<br />
*** LIPID PANEL, FASTING [80061B]<br />
*** LIPID PANEL, NON-FASTING [80061D]<br />
*** ALT, SERUM [84460B]<br />
*** PSA [84153B]<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** MICROALBUMIN/CREATININE, URINE [200479]<br />
** Standing Lab Orders<br />
*** HEMOGLOBIN A1C (HGB A1C) q 3 months for 1 year [83036B]<br />
* Procedures (with CPT codes)<br />
*** ANNUAL SCREENING, DM FOOT USING TOUCH PRESSURE QUANT. SENSORY TESTING, PER FOOT [0106TA]<br />
<br />
=== Another order set for diabetes, with a focus on complications ===<br />
<br />
* Diagnoses (with ICD-9 codes)<br />
** Diabetes related<br />
*** SENSORY PROBLEM W FEET, HIGH RISK [V49.3H]<br />
*** SENSORY PROBLEM W FEET, LOW RISK [V49.3I]<br />
*** SCREENING, DIABETIC RETINOPATHY [V72.0T]<br />
** Screening for other conditions<br />
*** SCREENING FOR CA, BREAST, BY MAMMOGRAM [V76.12G]<br />
*** SCREENING FOR CA, CERVIX [V76.2A]<br />
*** SCREENING FOR CA, COLON [V76.51A]<br />
*** SCREENING EXAMINATION FOR CA, PROSTATE [V76.44A]<br />
*** SCREENING, ENDOCRINE, NUTRITIONAL, OR METABOLIC [V77.99G]<br />
*** SCREENING [V82.9B]<br />
<br />
* Diabetes-related Orders (with CPT codes)<br />
** Lab today<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** LIPID PANEL [80061]<br />
*** LDL DIRECT [83721C]<br />
*** MICROALBUMIN SCREEN URINE [213757]<br />
*** ALT, SERUM [84460B]<br />
*** AST, SERUM [84450B]<br />
*** REF EYE CARE, DIABETIC SCREENING [217755]<br />
** Lab in 2-6 months<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** LIPID PANEL [80061]<br />
*** LDL DIRECT [83721C]<br />
*** MICROALBUMIN SCREEN URINE [213757]<br />
*** ALT, SERUM [84460B]<br />
*** AST, SERUM [84450B]<br />
** Lab in 6-12 months<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** LIPID PANEL [80061]<br />
*** LDL DIRECT [83721C]<br />
*** MICROALBUMIN SCREEN URINE [213757]<br />
*** ALT, SERUM [84460B]<br />
*** AST, SERUM [84450B]<br />
* Other related orders<br />
** Lab today<br />
*** CBC W DIFFERENTIAL, AUTO [85025B]<br />
*** SODIUM, SERUM [84295A]<br />
*** POTASSIUM BLOOD [84132A]<br />
*** CHLORIDE, SERUM [82435C]<br />
*** BUN, SERUM [84520M]<br />
*** CREATININE, SERUM [82565C]<br />
*** OCCULT BLOOD ST 3 SPECIMENS [82270A]<br />
*** PAP, LIQUID BASE SCREEN [88174C]<br />
*** PSA [84153B]<br />
*** TSH W REFLEX TO FT4 - order if screening [84443K]<br />
*** THYROID STIMULATING HORMONE (TSH ONLY)- order if monitoring [84443A]<br />
*** URINALYSIS W REFLEX TO MICROSCOPY AND CULTURE [81003G]<br />
* Referral, imaging and reminder orders<br />
*** FLEX SIG [214156]<br />
*** REF COLON CANCER SCREENING HI RISK (aka COLONOSCOPY) [213973]<br />
*** REMIND TO HAVE PAP EXAM [213594]<br />
*** XR MAMMOGRAPHY SCREENING BILATERAL, 2 VIEWS EACH BREAST [77057K]</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Diabetes_order_setsDiabetes order sets2007-09-11T18:58:18Z<p>AdamWright: </p>
<hr />
<div>These diabetes order sets are based on content released into the public domain by [[Kaiser Permanente]].<br />
<br />
Each order set contains a variety of common orders for patients with diabetes. One of the major questions in order set design is whether a good order set has all of the choices someone might want (which implies that an order set is a tool for making ordering quicker), or whether it should contain the "best" choices (which implies that an order set is a tool for influencing ordering behavior). These two order sets lean towards the side of inclusiveness, although they do make a careful effort to be evidence-based, and generally contain drugs available in a generic form in the United States.<br />
<br />
This flow sheet contains a set of lab results useful in the clinical management of a patient with diabetes. Many clinical information systems allow for the creation of flow sheets like this, so that specific subsets of lab results can be viewed by the user.<br />
<br />
=== An order set for Type II Diabetes, with a focus on DM management ===<br />
* Diagnoses (with ICD-9 codes)<br />
*** DM 2 [250.00H]<br />
*** DM 2 W DIABETIC NEPHROPATHY<br />
*** DM 2 W DIABETIC PERIPHERAL NEUROPATHY<br />
* Medications<br />
*** SURESTEP TEST STRIPS (Sig: Use as directed for diabetes, Disp: 100)<br />
*** ONE TOUCH ULTRASOFT LANCETS (Sig: Use as directed, Disp: 100)<br />
*** ONE TOUCH ULTRA 2 KIT (Sig: Use as directed, Disp: 1)<br />
*** ONE TOUCH ULTRA TEST STRIPS (Sig: Use as directed, Disp: 100)<br />
*** ASPIRIN 81 MG ORAL EC TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR DIABETES HEART PROTECTION, Disp: 100)<br />
*** ASPIRIN 325 MG ORAL EC TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR DIABETES HEART PROTECTION, Disp: 100)<br />
*** METFORMIN 500 MG ORAL TAB (Sig: TAKE 1 TAB PO BID FOR DIABETES, Disp: 120)<br />
*** METFORMIN 1,000 MG ORAL TAB (Sig: TAKE 1 TAB PO BID FOR DIABETES, Disp: 120)<br />
*** GLIPIZIDE 5 MG ORAL TAB (Sig: TAKE 1 TAB PO ONE DAILY FOR DIABETES, Disp: 60)<br />
*** GLIPIZIDE 5 MG ORAL TAB (Sig: TAKE 1 TAB PO BID FOR DIABETES, Disp: 120)<br />
*** GLIPIZIDE 10 MG ORAL TAB (Sig: TAKE 1 TAB PO ONE DAILY FOR DIABETES, Disp: 60)<br />
*** GLIPIZIDE 10 MG ORAL TAB (Sig: TAKE 1 TAB PO BID FOR DIABETES, Disp: 120)<br />
*** GLIPIZIDE 10 MG ORAL TAB (Sig: TAKE 2 TABS PO BID FOR DIABETES, Disp: 240)<br />
*** SIMVASTATIN 10 MG ORAL TAB (Sig: take 1 tab po once daily for cholesterol, Disp: 60)<br />
*** SIMVASTATIN 20 MG ORAL TAB (Sig: take 1 tab po once daily for cholesterol, Disp: 60)<br />
*** SIMVASTATIN 40 MG ORAL TAB (Sig: take 1 tab po once daily for cholesterol, Disp: 60)<br />
*** SIMVASTATIN 80 MG ORAL TAB (Sig: take 1 tab po once daily for cholesterol, Disp: 60)<br />
*** LISINOPRIL 10 MG ORAL TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL 20 MG ORAL TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL 40 MG ORAL TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL-HYDROCHLOROTHIAZIDE 10 MG-12.5 MG TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL-HYDROCHLOROTHIAZIDE 20 MG-12.5 MG TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL-HYDROCHLOROTHIAZIDE 20 MG-25 MG TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** NPH INSULIN 100 UNIT/ML INJ (Sig: INJECT SUBCUTANEOUSLY AS DIRECTED FOR DIABETES, Disp: 20)<br />
*** REGULAR INSULIN 100 UNIT/ML INJ (Sig: INJECT SUBCUTANEOUSLY AS DIRECTED FOR DIABETES, Disp: 20)<br />
* Immunizations (with CPT codes)<br />
** Immunization<br />
*** TDaP Vaccination 0.5 ml IM (ages 11-64) [90715A]<br />
*** Td (adult) vaccination, 0.5 mL IM (age 65 and over) [90718C]<br />
*** Pneumococcal Polysaccharide (Pneumovax) vaccination, 0.5 mL IM [90732C]<br />
*** Influenza vaccination, 3 yr - adult, 0.5 mL IM [90658C]<br />
*** Influenza vaccination, 0.5 mL IntraNasal [90660C]<br />
** Administration Codes<br />
*** VACC ADMIN, FIRST IM OR SUBQ VACCINE TOXOID (Always order) [90471B] <br />
*** VACC ADMIN, EACH ADDITIONAL IM OR SUBQ VACCINE TOXOID (For 2 or more total IMM's select FIRST IMM code above, and this code for each additional administration) [90472B]<br />
*** VACC ADMIN, FIRST INTRANASAL OR PO VACCINE TOXOID [90473B]<br />
* Lab orders (with CPT codes)<br />
** Labs today<br />
*** CBC W DIFFERENTIAL, AUTO [85025B]<br />
*** POTASSIUM, SERUM [84132C]<br />
*** CREATININE, SERUM [82565C]<br />
*** GLUCOSE, FASTING [82947B]<br />
*** ELECTROLYTES, SERUM [80051E]<br />
*** TSH W REFLEX TO FT4 [84443K]<br />
*** TSH ONLY [84443B]<br />
*** LIPID PANEL, FASTING [80061B]<br />
*** LIPID PANEL, NON-FASTING [80061D]<br />
*** ALT, SERUM [84460B]<br />
*** PSA [84153B]<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** MICROALBUMIN/CREATININE, URINE [200479]<br />
** Labs today<br />
*** CBC W DIFFERENTIAL, AUTO [85025B]<br />
*** CREATININE, SERUM [82565C]<br />
*** GLUCOSE, FASTING [82947B]<br />
*** ELECTROLYTES, SERUM [80051E]<br />
*** TSH W REFLEX TO FT4 [84443K]<br />
*** TSH ONLY [84443B]<br />
*** LIPID PANEL, FASTING [80061B]<br />
*** LIPID PANEL, NON-FASTING [80061D]<br />
*** ALT, SERUM [84460B]<br />
*** PSA [84153B]<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** MICROALBUMIN/CREATININE, URINE [200479]<br />
** Labs in 3-12 months<br />
*** CBC W DIFFERENTIAL, AUTO [85025B]<br />
*** CREATININE, SERUM [82565C]<br />
*** GLUCOSE, FASTING [82947B]<br />
*** ELECTROLYTES, SERUM [80051E]<br />
*** TSH W REFLEX TO FT4 [84443K]<br />
*** TSH ONLY [84443B]<br />
*** LIPID PANEL, FASTING [80061B]<br />
*** LIPID PANEL, NON-FASTING [80061D]<br />
*** ALT, SERUM [84460B]<br />
*** PSA [84153B]<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** MICROALBUMIN/CREATININE, URINE [200479]<br />
** Standing Lab Orders<br />
*** HEMOGLOBIN A1C (HGB A1C) q 3 months for 1 year [83036B]<br />
* Procedures (with CPT codes)<br />
*** ANNUAL SCREENING, DM FOOT USING TOUCH PRESSURE QUANT. SENSORY TESTING, PER FOOT [0106TA]<br />
<br />
=== Another order set for diabetes, with a focus on complications ===<br />
<br />
* Diagnoses (with ICD-9 codes)<br />
** Diabetes related<br />
*** SENSORY PROBLEM W FEET, HIGH RISK [V49.3H]<br />
*** SENSORY PROBLEM W FEET, LOW RISK [V49.3I]<br />
*** SCREENING, DIABETIC RETINOPATHY [V72.0T]<br />
** Screening for other conditions<br />
*** SCREENING FOR CA, BREAST, BY MAMMOGRAM [V76.12G]<br />
*** SCREENING FOR CA, CERVIX [V76.2A]<br />
*** SCREENING FOR CA, COLON [V76.51A]<br />
*** SCREENING EXAMINATION FOR CA, PROSTATE [V76.44A]<br />
*** SCREENING, ENDOCRINE, NUTRITIONAL, OR METABOLIC [V77.99G]<br />
*** SCREENING [V82.9B]<br />
<br />
* Diabetes-related Orders (with CPT codes)<br />
** Lab today<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** LIPID PANEL [80061]<br />
*** LDL DIRECT [83721C]<br />
*** MICROALBUMIN SCREEN URINE [213757]<br />
*** ALT, SERUM [84460B]<br />
*** AST, SERUM [84450B]<br />
*** REF EYE CARE, DIABETIC SCREENING [217755]<br />
** Lab in 2-6 months<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** LIPID PANEL [80061]<br />
*** LDL DIRECT [83721C]<br />
*** MICROALBUMIN SCREEN URINE [213757]<br />
*** ALT, SERUM [84460B]<br />
*** AST, SERUM [84450B]<br />
** Lab in 6-12 months<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** LIPID PANEL [80061]<br />
*** LDL DIRECT [83721C]<br />
*** MICROALBUMIN SCREEN URINE [213757]<br />
*** ALT, SERUM [84460B]<br />
*** AST, SERUM [84450B]<br />
* Other related orders<br />
** Lab today<br />
*** CBC W DIFFERENTIAL, AUTO [85025B]<br />
*** SODIUM, SERUM [84295A]<br />
*** POTASSIUM BLOOD [84132A]<br />
*** CHLORIDE, SERUM [82435C]<br />
*** BUN, SERUM [84520M]<br />
*** CREATININE, SERUM [82565C]<br />
*** OCCULT BLOOD ST 3 SPECIMENS [82270A]<br />
*** PAP, LIQUID BASE SCREEN [88174C]<br />
*** PSA [84153B]<br />
*** TSH W REFLEX TO FT4 - order if screening [84443K]<br />
*** THYROID STIMULATING HORMONE (TSH ONLY)- order if monitoring [84443A]<br />
*** URINALYSIS W REFLEX TO MICROSCOPY AND CULTURE [81003G]<br />
* Referral, imaging and reminder orders<br />
*** FLEX SIG [214156]<br />
*** REF COLON CANCER SCREENING HI RISK (aka COLONOSCOPY) [213973]<br />
*** REMIND TO HAVE PAP EXAM [213594]<br />
*** XR MAMMOGRAPHY SCREENING BILATERAL, 2 VIEWS EACH BREAST [77057K]</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Diabetes_order_setsDiabetes order sets2007-09-11T18:55:24Z<p>AdamWright: </p>
<hr />
<div>=== An order set for Type II Diabetes, with a focus on DM management ===<br />
* Diagnoses (with ICD-9 codes)<br />
*** DM 2 [250.00H]<br />
*** DM 2 W DIABETIC NEPHROPATHY<br />
*** DM 2 W DIABETIC PERIPHERAL NEUROPATHY<br />
* Medications<br />
*** SURESTEP TEST STRIPS (Sig: Use as directed for diabetes, Disp: 100)<br />
*** ONE TOUCH ULTRASOFT LANCETS (Sig: Use as directed, Disp: 100)<br />
*** ONE TOUCH ULTRA 2 KIT (Sig: Use as directed, Disp: 1)<br />
*** ONE TOUCH ULTRA TEST STRIPS (Sig: Use as directed, Disp: 100)<br />
*** ASPIRIN 81 MG ORAL EC TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR DIABETES HEART PROTECTION, Disp: 100)<br />
*** ASPIRIN 325 MG ORAL EC TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR DIABETES HEART PROTECTION, Disp: 100)<br />
*** METFORMIN 500 MG ORAL TAB (Sig: TAKE 1 TAB PO BID FOR DIABETES, Disp: 120)<br />
*** METFORMIN 1,000 MG ORAL TAB (Sig: TAKE 1 TAB PO BID FOR DIABETES, Disp: 120)<br />
*** GLIPIZIDE 5 MG ORAL TAB (Sig: TAKE 1 TAB PO ONE DAILY FOR DIABETES, Disp: 60)<br />
*** GLIPIZIDE 5 MG ORAL TAB (Sig: TAKE 1 TAB PO BID FOR DIABETES, Disp: 120)<br />
*** GLIPIZIDE 10 MG ORAL TAB (Sig: TAKE 1 TAB PO ONE DAILY FOR DIABETES, Disp: 60)<br />
*** GLIPIZIDE 10 MG ORAL TAB (Sig: TAKE 1 TAB PO BID FOR DIABETES, Disp: 120)<br />
*** GLIPIZIDE 10 MG ORAL TAB (Sig: TAKE 2 TABS PO BID FOR DIABETES, Disp: 240)<br />
*** SIMVASTATIN 10 MG ORAL TAB (Sig: take 1 tab po once daily for cholesterol, Disp: 60)<br />
*** SIMVASTATIN 20 MG ORAL TAB (Sig: take 1 tab po once daily for cholesterol, Disp: 60)<br />
*** SIMVASTATIN 40 MG ORAL TAB (Sig: take 1 tab po once daily for cholesterol, Disp: 60)<br />
*** SIMVASTATIN 80 MG ORAL TAB (Sig: take 1 tab po once daily for cholesterol, Disp: 60)<br />
*** LISINOPRIL 10 MG ORAL TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL 20 MG ORAL TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL 40 MG ORAL TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL-HYDROCHLOROTHIAZIDE 10 MG-12.5 MG TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL-HYDROCHLOROTHIAZIDE 20 MG-12.5 MG TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** LISINOPRIL-HYDROCHLOROTHIAZIDE 20 MG-25 MG TAB (Sig: TAKE 1 TAB PO ONCE DAILY FOR BLOOD PRESSURE AND KIDNEY PROTECTION, Disp: 60)<br />
*** NPH INSULIN 100 UNIT/ML INJ (Sig: INJECT SUBCUTANEOUSLY AS DIRECTED FOR DIABETES, Disp: 20)<br />
*** REGULAR INSULIN 100 UNIT/ML INJ (Sig: INJECT SUBCUTANEOUSLY AS DIRECTED FOR DIABETES, Disp: 20)<br />
* Immunizations (with CPT codes)<br />
** Immunization<br />
*** TDaP Vaccination 0.5 ml IM (ages 11-64) [90715A]<br />
*** Td (adult) vaccination, 0.5 mL IM (age 65 and over) [90718C]<br />
*** Pneumococcal Polysaccharide (Pneumovax) vaccination, 0.5 mL IM [90732C]<br />
*** Influenza vaccination, 3 yr - adult, 0.5 mL IM [90658C]<br />
*** Influenza vaccination, 0.5 mL IntraNasal [90660C]<br />
** Administration Codes<br />
*** VACC ADMIN, FIRST IM OR SUBQ VACCINE TOXOID (Always order) [90471B] <br />
*** VACC ADMIN, EACH ADDITIONAL IM OR SUBQ VACCINE TOXOID (For 2 or more total IMM's select FIRST IMM code above, and this code for each additional administration) [90472B]<br />
*** VACC ADMIN, FIRST INTRANASAL OR PO VACCINE TOXOID [90473B]<br />
* Lab orders (with CPT codes)<br />
** Labs today<br />
*** CBC W DIFFERENTIAL, AUTO [85025B]<br />
*** POTASSIUM, SERUM [84132C]<br />
*** CREATININE, SERUM [82565C]<br />
*** GLUCOSE, FASTING [82947B]<br />
*** ELECTROLYTES, SERUM [80051E]<br />
*** TSH W REFLEX TO FT4 [84443K]<br />
*** TSH ONLY [84443B]<br />
*** LIPID PANEL, FASTING [80061B]<br />
*** LIPID PANEL, NON-FASTING [80061D]<br />
*** ALT, SERUM [84460B]<br />
*** PSA [84153B]<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** MICROALBUMIN/CREATININE, URINE [200479]<br />
** Labs today<br />
*** CBC W DIFFERENTIAL, AUTO [85025B]<br />
*** CREATININE, SERUM [82565C]<br />
*** GLUCOSE, FASTING [82947B]<br />
*** ELECTROLYTES, SERUM [80051E]<br />
*** TSH W REFLEX TO FT4 [84443K]<br />
*** TSH ONLY [84443B]<br />
*** LIPID PANEL, FASTING [80061B]<br />
*** LIPID PANEL, NON-FASTING [80061D]<br />
*** ALT, SERUM [84460B]<br />
*** PSA [84153B]<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** MICROALBUMIN/CREATININE, URINE [200479]<br />
** Labs in 3-12 months<br />
*** CBC W DIFFERENTIAL, AUTO [85025B]<br />
*** CREATININE, SERUM [82565C]<br />
*** GLUCOSE, FASTING [82947B]<br />
*** ELECTROLYTES, SERUM [80051E]<br />
*** TSH W REFLEX TO FT4 [84443K]<br />
*** TSH ONLY [84443B]<br />
*** LIPID PANEL, FASTING [80061B]<br />
*** LIPID PANEL, NON-FASTING [80061D]<br />
*** ALT, SERUM [84460B]<br />
*** PSA [84153B]<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** MICROALBUMIN/CREATININE, URINE [200479]<br />
** Standing Lab Orders<br />
*** HEMOGLOBIN A1C (HGB A1C) q 3 months for 1 year [83036B]<br />
* Procedures (with CPT codes)<br />
*** ANNUAL SCREENING, DM FOOT USING TOUCH PRESSURE QUANT. SENSORY TESTING, PER FOOT [0106TA]<br />
<br />
=== Another order set for diabetes, with a focus on complications ===<br />
<br />
* Diagnoses (with ICD-9 codes)<br />
** Diabetes related<br />
*** SENSORY PROBLEM W FEET, HIGH RISK [V49.3H]<br />
*** SENSORY PROBLEM W FEET, LOW RISK [V49.3I]<br />
*** SCREENING, DIABETIC RETINOPATHY [V72.0T]<br />
** Screening for other conditions<br />
*** SCREENING FOR CA, BREAST, BY MAMMOGRAM [V76.12G]<br />
*** SCREENING FOR CA, CERVIX [V76.2A]<br />
*** SCREENING FOR CA, COLON [V76.51A]<br />
*** SCREENING EXAMINATION FOR CA, PROSTATE [V76.44A]<br />
*** SCREENING, ENDOCRINE, NUTRITIONAL, OR METABOLIC [V77.99G]<br />
*** SCREENING [V82.9B]<br />
<br />
* Diabetes-related Orders (with CPT codes)<br />
** Lab today<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** LIPID PANEL [80061]<br />
*** LDL DIRECT [83721C]<br />
*** MICROALBUMIN SCREEN URINE [213757]<br />
*** ALT, SERUM [84460B]<br />
*** AST, SERUM [84450B]<br />
*** REF EYE CARE, DIABETIC SCREENING [217755]<br />
** Lab in 2-6 months<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** LIPID PANEL [80061]<br />
*** LDL DIRECT [83721C]<br />
*** MICROALBUMIN SCREEN URINE [213757]<br />
*** ALT, SERUM [84460B]<br />
*** AST, SERUM [84450B]<br />
** Lab in 6-12 months<br />
*** HEMOGLOBIN A1C [83036B]<br />
*** LIPID PANEL [80061]<br />
*** LDL DIRECT [83721C]<br />
*** MICROALBUMIN SCREEN URINE [213757]<br />
*** ALT, SERUM [84460B]<br />
*** AST, SERUM [84450B]<br />
* Other related orders<br />
** Lab today<br />
*** CBC W DIFFERENTIAL, AUTO [85025B]<br />
*** SODIUM, SERUM [84295A]<br />
*** POTASSIUM BLOOD [84132A]<br />
*** CHLORIDE, SERUM [82435C]<br />
*** BUN, SERUM [84520M]<br />
*** CREATININE, SERUM [82565C]<br />
*** OCCULT BLOOD ST 3 SPECIMENS [82270A]<br />
*** PAP, LIQUID BASE SCREEN [88174C]<br />
*** PSA [84153B]<br />
*** TSH W REFLEX TO FT4 - order if screening [84443K]<br />
*** THYROID STIMULATING HORMONE (TSH ONLY)- order if monitoring [84443A]<br />
*** URINALYSIS W REFLEX TO MICROSCOPY AND CULTURE [81003G]<br />
* Referral, imaging and reminder orders<br />
*** FLEX SIG [214156]<br />
*** REF COLON CANCER SCREENING HI RISK (aka COLONOSCOPY) [213973]<br />
*** REMIND TO HAVE PAP EXAM [213594]<br />
*** XR MAMMOGRAPHY SCREENING BILATERAL, 2 VIEWS EACH BREAST [77057K]</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Diabetes_alerts_and_remindersDiabetes alerts and reminders2007-09-11T15:32:37Z<p>AdamWright: </p>
<hr />
<div>These diabetes alerts and reminders are based on content released into the public domain by [[Kaiser Permanente]].<br />
<br />
==== Patient overdue for hemoglobin A1c ====<br />
<pre><br />
if the patient<br />
has diabetes on their problem list,<br />
is <100 years old,<br />
is not terminally ill,<br />
does not have a flag indicating that the HbA1c is not clinically indicated,<br />
has not had a HbA1c in the last 12 months<br />
then<br />
suggest a HbA1c.<br />
</pre></div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Diabetes_CDS_ContentDiabetes CDS Content2007-09-11T15:28:27Z<p>AdamWright: </p>
<hr />
<div>The diabetes decision support content posted here is based on content released into the public domain by [[Kaiser Permanente]].<br />
<br />
* [[Diabetes lab flow sheets]]<br />
* [[Diabetes order sets]]<br />
* [[Diabetes alerts and reminders]]</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Diabetes_lab_flow_sheetsDiabetes lab flow sheets2007-09-11T15:28:01Z<p>AdamWright: </p>
<hr />
<div>This diabetes lab flow sheet is based on content released into the public domain by [[Kaiser Permanente]].<br />
<br />
This flow sheet contains a set of lab results useful in the clinical management of a patient with diabetes. Many clinical information systems allow for the creation of flow sheets like this, so that specific subsets of lab results can be viewed by the user.<br />
<br />
* Fructosamine <br />
* HbA1c<br />
* Cholesterol <br />
* HDL Cholesterol <br />
* LDL Cholesterol <br />
* Fasting Triglycerides<br />
* Creatinine <br />
* Urine Protein <br />
* Protein Rate, 24 Hr Urine <br />
* Fasting Glucose <br />
* Random Glucose <br />
* Microalbumin 24 Hr <br />
* Albumin Excretion Rate<br />
* Specimen Volume, Urine <br />
* Urine Collection Time Interval <br />
* Collection Duration, Urine <br />
* Microalbumin / Creatinine Ratio</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Diabetes_lab_flow_sheetsDiabetes lab flow sheets2007-09-11T15:27:33Z<p>AdamWright: </p>
<hr />
<div>This diabetes lab flow sheet is based on content released into the public domain by [[Kaiser Permanente]].<br />
<br />
This flow sheet contains a set of lab results useful in the clinical management of a patient with diabetes. Many clinical information systems allow for the creation of flow sheets like this, so that specific subsets of lab results can be viewed by the user.<br />
<br />
* Fructosamine <br />
* HbA1c<br />
* Cholesterol <br />
* HDL Cholesterol <br />
* LDL Cholesterol <br />
* Fasting Triglycerides<br />
* Creatinine <br />
* Urine Protein <br />
* Protein Rate, 24 Hr Urine <br />
* Fasting Glucose <br />
* Random Glucose <br />
* Microalbumin 24 Hr <br />
* Albumin Excretion Rate<br />
* Specimen Volume, Urine <br />
* Urine Collection Time Interval <br />
* Collection Duration, Urine <br />
* Microalbum / Creatinine Ratio</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/Diabetes_CDS_ContentDiabetes CDS Content2007-09-11T15:25:09Z<p>AdamWright: </p>
<hr />
<div>The diabetes decision support content posted here is based on content released into the public domain by [[Kaiser Permanente]].<br />
<br />
* [[Diabetes lab flow sheets]]<br />
* [[Diabetes order sets]]<br />
* [[Diabetes alert and reminders]]</div>AdamWrighthttp://clinfowiki.org/wiki/index.php/CDSCDS2007-09-11T15:22:53Z<p>AdamWright: </p>
<hr />
<div>==Clinical Decision Support -- CDS==<br />
<br />
===Overview===<br />
<br />
Clinical Decision Support (CDS) refers broadly to providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care. Clinical knowledge of interest could range from simple facts and relationships to best practices for managing patients with specific disease states, new medical knowledge from clinical research and other types of information.<br />
<br />
For an overview of the process that healthcare organizations can use to begin, or improve, a clinical decision support (CDS) initiative interested parties can follow the guidelines described in <br />
[http://www.himss.org/ASP/topics_cds_workbook.asp?faid=108&tid=14 Improving Outcomes with Clinical Decision Suppport: An Implementer's Guide] to measurably improve key healthcare outcomes such as the quality, safety, and cost-effectiveness of care delivery.<br />
<br />
*[[National Roadmap for Clinical Decision Support]]<br />
*[[History of decision support]]<br />
*[[General system features associated with improvements in clinical practice]]<br />
*[http://wellness.wikispaces.com/Tactic+-+Support+Decisions+with+Diagnostic+Aids Support Decisions with Diagnostic Aids]<br />
*[[Clinical Decision Support Liability]]<br />
<br />
===[[Modes of Interaction]]===<br />
*[[Interpretation]]<br />
*[[Consultation]]<br />
*[[Monitoring]]<br />
*[[Critiquing]]<br />
*[[Teaching]]<br />
<br />
===[[Order Sets]]===<br />
*[[Personal Order Sets]]<br />
*[[Functional Specifications]]<br />
*[[Criteria for creating new order sets]]<br />
*[[A Process for Creating and Maintaining Order Sets]]<br />
<br />
===[[Information Resources]]===<br />
*[[Alerts and Reminders]]<br />
*[[Alert Fatigue]]?<br />
*[[Alert placement in clinical workflow]]<br />
*[[Initial Selection of What to Alert on...]]<br />
<br />
===Examples available on the web===<br />
*[[GIDEON|GIDEON (Global Infectious Diseases and Epidemiology Network)]]<br />
*[[Isabel (diagnostic decision support system)]]<br />
[[:Category:CDS|All articles related to clinical decision support]]<br />
<br />
===Business Intelligence and Data Warehousing===<br />
*[[Business Intelligence & Data Warehousing for Healthcare]]<br />
*[[Clinical Data Warehousing]]<br />
<br />
===Medication-Based Safety Rules===<br />
*[[Potentially Inappropriate Medication (PIM) Use in Older Adults:65 years and older (Based on 2000 updated Beers Criteria)]]<br />
**[[List of some PIM use independent of patient conditions and diagnosis (drugs with ADE severity rating of HIGH only)]]<br />
**[[List of some PIM use for patient with specific conditions (drugs with ADE severity rating of HIGH only)]]<br />
*[[Medications to be avoided in the elderly]]<br />
*[[Medications requiring dosage adjustments in renal insufficiency]]<br />
*[[Common Corollary orders]]<br />
*[[Drug-Laboratory Interactions]]<br />
*[[Drug-Drug interaction]]<br />
*[[Drug-Allergy Interactions]]<br />
*[[Detection of Adverse Mediation-Related Events]]<br />
*[[Drug-Food Interactions]]<br />
*[[Drug-Tobacco Interactions]]<br />
*[[Medications requiring dosage adjustments in hepatic disease]]<br />
<br />
===Non-Medication-Based Safety Rules===<br />
* [[Diagnosis-Order Rules]]<br />
<br />
===Validation and Verification of Clinical Decision Support===<br />
*[[On Validation and Verification Of Decision Support Protocol Subsystems During Implementation-Optimization: Encapsulating P(X)]]<br />
<br />
===Sample Decision Support Content===<br />
* [[Diabetes CDS Content]]</div>AdamWright