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Exceptions: Levocabastine (Nasal). Risk C: Monitor therapy Antipsychotic Agents (Phenothiazines): May enhance the hypotensive effect of Analgesics (Opioid). Risk C: Monitor therapy Azelastine (Nasal): CNS Depressants may enhance the CNS depressant effect of Azelastine (Nasal). Risk X: Avoid combination Cannabinoids: Anticholinergic Agents may enhance the tachycardic effect of Cannabinoids. Risk C: Monitor therapy CNS Depressants: May enhance the adverse/toxic effect of other CNS Depressants.

Exceptions: Levocabastine (Nasal). Risk C: Monitor therapy Desmopressin: Analgesics (Opioid) may enhance the adverse/toxic effect of Desmopressin. Risk C: Monitor therapy Droperidol: May enhance the CNS depressant effect of CNS Depressants. Management: Consider dose reductions of droperidol or of other CNS agents (e.g., opioids, barbiturates) with concomitant use. Risk D: Consider therapy modification HydrOXYzine: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy Ipratropium (Oral Inhalation): May enhance the anticholinergic effect of Anticholinergics. Risk X: Avoid combination Magnesium Sulfate: May enhance the CNS depressant effect of CNS Depressants. Risk C: Monitor therapy MAO Inhibitors: May enhance the orthostatic hypotensive effect of Orthostatic Hypotension Producing Agents. Risk C: Monitor therapy Metyrosine: CNS Depressants may enhance the sedative effect of Metyrosine. Risk C: Monitor therapy Mirabegron: Anticholinergic Agents may enhance the therapeutic effect of Mirabegron. This may result in acute urinary retention. Risk C: Monitor therapy Mirtazapine: CNS Depressants may enhance the CNS depressant effect of Mirtazapine. Risk C: Monitor therapy Mixed Agonist / Antagonist Opioids: May diminish the analgesic effect of Analgesics (Opioid). Management: Seek alternatives to mixed agonist/antagonist opioids in patients receiving pure opioid agonists, and monitor for symptoms of therapeutic failure/high dose requirements (or withdrawal in opioid-dependent patients) if patients receive these combinations. Risk D: Consider therapy modification OnabotulinumtoxinA: Anticholinergic Agents may enhance the anticholinergic effect of OnabotulinumtoxinA. Risk C: Monitor therapy Paraldehyde: CNS Depressants may enhance the CNS depressant effect of Paraldehyde. Risk X: Avoid combination Pegvisomant: Analgesics (Opioid) may diminish the therapeutic effect of Pegvisomant. Risk C: Monitor therapy Perampanel: May enhance the CNS depressant effect of CNS Depressants. Management: Patients taking perampanel with any other drug that has CNS depressant activities should avoid complex and high-risk activities, particularly those such as driving that require alertness and coordination, until they have experience using the combination. Risk D: Consider therapy modification

Perampanel: May enhance the CNS depressant effect of CNS Depressants. Management: Patients taking perampanel with any other drug that has CNS depressant activities should avoid complex and high-risk activities, particularly those such as driving that require alertness and coordination, until they have experience using the combination. Risk D: Consider therapy modification Potassium Chloride: Anticholinergic Agents may enhance the ulcerogenic effect of Potassium Chloride. Management: Patients on drugs with substantial anticholinergic effects should avoid using any solid oral dosage form of potassium chloride. Risk X: Avoid combination Pramipexole: CNS Depressants may enhance the sedative effect of Pramipexole. Risk C: Monitor therapy Pramlintide: May enhance the anticholinergic effect of Anticholinergics. These effects are specific to the GI tract. Risk D: Consider therapy modification RimabotulinumtoxinB: Anticholinergic Agents may enhance the anticholinergic effect of RimabotulinumtoxinB. Risk C: Monitor therapy ROPINIRole: CNS Depressants may enhance the sedative effect of ROPINIRole. Risk C: Monitor therapy Rotigotine: CNS Depressants may enhance the sedative effect of Rotigotine. Risk C: Monitor therapy Secretin: Anticholinergic Agents may diminish the therapeutic effect of Secretin. Risk D: Consider therapy modification Selective Serotonin Reuptake Inhibitors: Analgesics (Opioid) may enhance the serotonergic effect of Selective Serotonin Reuptake Inhibitors. This may cause serotonin syndrome. Risk C: Monitor therapy Sodium Oxybate: May enhance the CNS depressant effect of CNS Depressants. Management: Consider alternatives to combined use. When combined use is needed, consider minimizing doses of one or more drugs. Use of sodium oxybate with alcohol or sedative hypnotics is contraindicated. Risk D: Consider therapy modification Succinylcholine: May enhance the bradycardic effect of Analgesics (Opioid). Risk C: Monitor therapy Thiazide Diuretics: Analgesics (Opioid) may enhance the orthostatic hypotensive effect of Thiazide Diuretics. Risk C: Monitor therapy Tiotropium: Anticholinergics may enhance the anticholinergic effect of Tiotropium. Risk X: Avoid combination Topiramate: Anticholinergic Agents may enhance the adverse/toxic effect of Topiramate. Specifically, the risk of oligohidrosis and hyperthermia may be enhanced. Risk C: Monitor therapy

Thiazide Diuretics: Analgesics (Opioid) may enhance the orthostatic hypotensive effect of Thiazide Diuretics. Risk C: Monitor therapy Tiotropium: Anticholinergics may enhance the anticholinergic effect of Tiotropium. Risk X: Avoid combination Topiramate: Anticholinergic Agents may enhance the adverse/toxic effect of Topiramate. Specifically, the risk of oligohidrosis and hyperthermia may be enhanced. Risk C: Monitor therapy Zolpidem: CNS Depressants may enhance the CNS depressant effect of Zolpidem. Management: Reduce the Intermezzo brand sublingual zolpidem dose to 1.75 mg for men who are also receiving other CNS depressants. No such dose change is recommended for women. Avoid use with other CNS depressants at bedtime; avoid use with alcohol. Risk D: Consider therapy modification Food Interactions Avoid ethanol (may increase sedation). Pregnancy Risk Factor C ( show table ) Pregnancy Implications Reproduction studies have not been conducted with this product. Refer to Atropine and Morphine Sulfate monographs for additional information. Mechanism of Action Anticholinergic alkaloids act primarily by competitive inhibition of the muscarinic actions of acetylcholine on structures innervated by postganglionic cholinergic neurons and on smooth muscle; resulting effects include antisecretory activity on exocrine glands and intestinal mucosa and smooth muscle relaxation. Contains many narcotic alkaloids including morphine; its mechanism for gastric motility inhibition is primarily due to this morphine content; it results in a decrease in digestive secretions, an increase in GI muscle tone, and therefore a reduction in GI propulsion. Pharmacodynamics Opium: Onset of action: Within 30 minutes Pharmacokinetics (Adult data unless noted) Metabolism: Hepatic Patient Information (For additional information see "Belladonna and opium: Patient drug information" ) Drug may cause physical and/or psychological dependence; avoid abrupt discontinuation after prolonged use. Avoid alcohol; may cause drowsiness and impair ability to perform activities requiring mental alertness or physical coordination; may cause dry mouth Use of UpToDate is subject to the Subscription and License Agreement . Topic 13204 Version 40.0

Drug may cause physical and/or psychological dependence; avoid abrupt discontinuation after prolonged use. Avoid alcohol; may cause drowsiness and impair ability to perform activities requiring mental alertness or physical coordination; may cause dry mouth Use of UpToDate is subject to the Subscription and License Agreement . Topic 13204 Version 40.0 © 2013 UpToDate, Inc. All rights reserved. | Subscription and License Agreement | Release: 21.4 - C21.36 Licensed to: Southeast Alabama Med Ctr | Support Tag: [0604-115.66.252.144-403C6C9E42-S244013.14]