OBJECT DRUGS
MAO Inhibitors (Nonselective):
MAO-B Inhibitors:
- Rasagiline (Azilect)
- Selegiline (Eldepryl, etc.)
PRECIPITANT DRUGS
Serotonergic Drugs:
- Buspirone (BuSpar)
- Citalopram (Celexa)
- Cyclobenzaprine (Flexeril, etc.)
- Desvenlafaxine (Pristiq, etc.)
- Dextromethorphan
- Duloxetine (Cymbalta)
- Escitalopram (Lexapro)
- Fentanyl (Sublimaze, etc.)
- Fluoxetine (Prozac, etc.)
- Fluvoxamine (Luvox, etc.)
- Meperidine (Demerol)
- Milnacipran (Savella)
- Mirtazapine (Remeron, etc.)
- Paroxetine (Paxil, etc.)
- Propoxyphene*
- Sertraline (Zoloft)
- Tapentadol (Nucynta, etc.)
- Tetrabenazine (Xenazine)
- Tramadol (Ultram, etc.)
- Trazodone (Desyrel)
- Venlafaxine (Effexor)
- Vilazodone (Viibryd)
* Propoxyphene (Darvon) was withdrawn from the US market.
Comment:
Linezolid appears to be a weak MAOI, but serotonin syndrome has been reported when it is combined with serotonergic agents, including SSRIs and SNRIs. Selective MAO-B inhibitors theoretically should not interact with serotonergic drugs, and many patients have received these combinations safely. Some patients on MAO-B inhibitors, however, may develop nonselective MAO inhibition. Rasagiline is metabolized by CYP1A2, so theoretically, patients on CYP1A2 inhibitors may be more likely to develop nonselective MAO inhibition due to rasagiline. (For a list of CYP1A2 inhibitors, see CYP 450 Table at front of book.) (Note: Concurrent use of 2 or more serotonergic drugs (from the 2 right columns above) may increase the risk of serotonin syndrome, but only isolated cases have been reported.)
Class 2: Use only if Benefit Felt to Outweigh Risk
- Use Alternative: If possible use an alternative to the serotonergic drug in patients on linezolid or MAO-B inhibitors. Note that some of these combinations may be listed as contraindicated in the product information. Depending on the antibiogram, consider alternative antibiotics such as vancomycin or telavancin (Vibativ) for linezolid.
- Monitor: If serotonergic drugs are used with linezolid or MAO-B inhibitors, monitor for evidence of serotonin syndrome (myoclonus, rigidity, tremor, hyperreflexia, fever, sweating, seizures, confusion, agitation, incoordination, and coma).