OBJECT DRUGS

Codeine Derivatives:

• Codeine
• Dihydrocodeine (Synalgos-DC)
• Hydrocodone (Vicodin, Lortab)
• Oxycodone (Percodan, Percocet, etc.)

PRECIPITANT DRUGS

Antidepressants:

• Bupropion (Wellbutrin, etc.)
• Duloxetine (Cymbalta)
• Fluoxetine (Prozac, etc.)
• Paroxetine (Paxil, etc.)

Comment:

Antidepressants that inhibit CYP2D6 prevent the conversion of codeine to its active metabolite, morphine; inhibition of analgesic effect may result. Preliminary evidence suggests that the analgesic effect of hydrocodone, oxycodone, and dihydrocodeine is also inhibited with reduced CYP2D6 activity. The analgesic effect of tramadol (Ultram) appears to be only partially dependent on CYP2D6, and thus it may have some analgesic activity in the presence of CYP2D6 inhibitors.

Class 3: Assess Risk & Take Action if Necessary

• Consider Alternative:
• Analgesic: Consider using an analgesic that does not require conversion to an active metabolite, e.g., morphine, methadone (Dolophine), fentanyl (Duragesic), hydromorphone (Dilaudid), butorphanol (Stadol), or oxymorphone (Numorphan).
• Antidepressant: Citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft) are weak inhibitors of CYP2D6, desvenlafaxine (Pristiq), venlafaxine (Effexor) and fluvoxamine (Luvox) have little or no effect on CYP2D6
• Monitor: Monitor for loss of analgesic efficacy.