Bismuth Subsalicylate; Metronidazole; Tetracycline: Moderate Due to a possible risk for QT prolongation and torsade de pointes TdP , azithromycin and metronidazole should be used together cautiously. Budesonide; Formoterol: Moderate Due to a possible risk for QT prolongation and torsade de pointes TdP , azithromycin and long-acting beta-agonists should be used together cautiously.
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Buprenorphine: Major Due to the potential for QT prolongation, cautious use and close monitoring are advisable if concurrent use of azithromycin and buprenorphine is necessary. Buprenorphine has been associated with QT prolongation and has a possible risk of torsade de pointes TdP. There have been case reports of QT prolongation and torsade de pointes TdP with the use of azithromycin in post-marketing reports.
FDA-approved labeling for some buprenorphine products recommend avoiding use with Class 1A and Class III antiarrhythmic medications while other labels recommend avoiding use with any drug that has the potential to prolong the QT interval. In addition, since the metabolism of buprenorphine is mediated by CYP3A4, co-administration of a CYP3A4 inhibitor such as azithromycin may decrease the clearance of buprenorphine resulting in prolonged or increased opioid effects. If co-administration is necessary, monitor patients for QT prolongation, respiratory depression and sedation at frequent intervals and consider dose adjustments until stable drug effects are achieved.
The effect of CYP3A4 inhibitors on buprenorphine implants has not been studied. Buprenorphine; Naloxone: Major Due to the potential for QT prolongation, cautious use and close monitoring are advisable if concurrent use of azithromycin and buprenorphine is necessary.
Caffeine; Ergotamine: Minor The manufacturer of azithromycin recommends caution and careful monitoring of patients who receive azithromycin and ergotamine, because simultaneous use of ergotamine with other macrolides may produce ergot toxicity. Ceritinib: Major Avoid coadministration of ceritinib with azithromycin if possible due to the risk of QT prolongation.
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If concomitant use is unavoidable, periodically monitor ECGs and electrolytes; an interruption of ceritinib therapy, dose reduction, or discontinuation of therapy may be necessary if QT prolongation occurs. Ceritinib causes concentration-dependent QT prolongation. Prolongation of the QT interval and torsade de pointes TdP have been spontaneously reported during azithromycin postmarketing surveillance.
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Chloroquine: Major The need to coadminister chloroquine with other drugs known to prolong the QT interval, such as azithromycin, should be done with a careful assessment of risks versus benefits and should be avoided when possible. Chloroquine is associated with an increased risk of QT prolongation and torsade de pointes TdP. Cases of QT prolongation and TdP have been reported during post-marketing use of azithromycin. Chlorpromazine: Major Agents that prolong the QT interval, such as azithromycin, could lead to torsade de pointes TdP when combined with a phenothiazine, and therefore are generally not recommended for combined use.
This risk is generally higher at elevated drugs concentrations of phenothiazines.
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Chlorpromazine is specifically associated with an established risk of QT prolongation and TdP; case reports have included patients receiving therapeutic doses of chlorpromazine. Cases of QT prolongation and TdP were also reported during the post-marketing use of azithromycin. Ciprofloxacin: Moderate Due to a possible risk for QT prolongation and torsade de pointes TdP , azithromycin and ciprofloxacin should be used together cautiously. Rare cases of QT prolongation and TdP have been reported with ciprofloxacin during postmarketing surveillance. Cisapride: Severe There have been case reports of QT prolongation and torsade de pointes TdP with the use of azithromycin in post-marketing reports.
Azithromycin is contraindicated with other drugs that have been specifically established that have a causal association with QT prolongation and torsade de pointes, such as cisapride. Citalopram: Major Concurrent use of citalopram with azithromycin is not recommended due to an increased risk for QT prolongation and torsade de pointes TdP. Citalopram causes dose-dependent QT interval prolongation, and azithromycin has been associated with cases of QT prolongation and TdP.
If concurrent therapy is considered essential, ECG monitoring is recommended. Clarithromycin: Major Both clarithromycin and azithromycin are macrolide antibiotics and coadministration would represent duplicate therapy. QT prolongation and torsade de pointes TdP have been reported in patients receiving clofazimine in combination with QT prolonging medications.
QT prolongation and TdP have been spontaneously reported during azithromycin postmarketing surveillance. Clomipramine: Minor Due to a possible risk for QT prolongation and torsade de pointes TdP , azithromycin and tricyclic antidepressants TCAs should be used together cautiously.
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Clozapine: Moderate Consider the risk of QT prolongation which can be fatal when administering azithromycin to patients on other QT prolonging agents such as clozapine. Treatment with clozapine has been associated with QT prolongation, TdP, cardiac arrest, and sudden death. Codeine; Phenylephrine; Promethazine: Moderate Consider the risk of QT prolongation which can be fatal when administering azithromycin to patients on other QT prolonging agents such as promethazine.
Promethazine is a phenothiazine that is associated with possible risk for QT prolongation.
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Codeine; Promethazine: Moderate Consider the risk of QT prolongation which can be fatal when administering azithromycin to patients on other QT prolonging agents such as promethazine. Colchicine: Moderate Caution is warranted with the concomitant use of colchicine and azithromycin as increased colchicine concentrations may occur.
Monitor for colchicine toxicity. Colchicine accumulation may be greater in patients with renal or hepatic impairment. Coadministration with azithromycin resulted in an increase in colchicine Cmax of Colchicine; Probenecid: Moderate Caution is warranted with the concomitant use of colchicine and azithromycin as increased colchicine concentrations may occur. Conjugated Estrogens; Bazedoxifene: Moderate In clinical evaluation, azithromycin mg was given once daily for 8 consecutive days in 30 postmenopausal women.
Azithromycin mg and a bazedoxifene 40 mg tablet were co-administered on Day 9. Azithromycin mg administration once daily continued on Days 10 to The clinical effect of this change is not known. A reduction in bazedoxifene exposure may be associated with an increased risk of endometrial hyperplasia. Monitor patients for loss of efficacy and increased side effects during conjugated estrogens; bazedoxifene therapy.
Crizotinib: Major Avoid coadministration of crizotinib with azithromycin due to the risk of QT prolongation.
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An interruption of therapy, dose reduction, or discontinuation of therapy may be necessary for crizotinib if QT prolongation occurs. Crizotinib has been associated with concentration-dependent QT prolongation. Cyclosporine: Moderate Caution is warranted with the concomitant use of azithromycin and cyclosporine as increased cyclosporine concentrations may occur. Dose adjustment of cyclosporine may be necessary; monitor cyclosporine serum concentrations during use with azithromycin and after discontinuation of azithromycin.
Dasatinib: Moderate Due to an increased risk for QT prolongation and torsade de pointes TdP , caution is advised during coadministration of dasatinib and azithromycin. In vitro studies have shown that dasatinib has the potential to prolong cardiac ventricular repolarization prolong QT interval. Additionally, cases of QT prolongation and TdP have been reported during the post-marketing use of azithromycin.
Degarelix: Moderate Consider whether the benefits of androgen deprivation therapy outweigh the potential risks in patients receiving azithromycin as concurrent use may increase the risk of QT prolongation.
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Androgen deprivation therapy i. Desflurane: Major Halogenated Anesthetics should be used cautiously and with close monitoring with azithromycin. Halogenated Anesthetics can prolong the QT interval. Desipramine: Minor Due to a possible risk for QT prolongation and torsade de pointes TdP , azithromycin and tricyclic antidepressants TCAs should be used together cautiously. Clinically relevant QTc prolongation may occur with deutetrabenazine. Dextromethorphan; Promethazine: Moderate Consider the risk of QT prolongation which can be fatal when administering azithromycin to patients on other QT prolonging agents such as promethazine.
Dextromethorphan; Quinidine: Major Due to an increased risk for QT prolongation and torsade de pointes TdP , caution is advised when coadministering quinidine with azithromycin. Quinidine is associated with QT prolongation and TdP, and rare cases of QT prolongation and TdP have been reported during the postmarketing use of azithromycin. Dienogest; Estradiol valerate: Moderate It would be prudent to recommend alternative or additional contraception when oral contraceptives OCs are used in conjunction with antibiotics.
It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported.
It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs e. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use.
Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives.
These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries e.
Digoxin: Moderate Monitor digoxin concentrations before and during concomitant use of azithromycin and reduce the digoxin dose if necessary.