OBJECT DRUGS
MAO Inhibitors (nonselective):
MAO-B Inhibitors:
- Rasagiline (Azilect)
- Safinamide (Xadago)
- Selegiline (Eldepryl, etc.)
PRECIPITANT DRUGS
Serotonergic Drugs:
- Citalopram (Celexa)
- Cyclobenzaprine (Flexeril, etc.)
- Desvenlafaxine (Pristiq, etc.)
- Dextromethorphan
- Duloxetine (Cymbalta)
- Escitalopram (Lexapro)
- Fentanyl (Sublimaze, etc.)
- Fluoxetine (Prozac, etc.)
- Fluvoxamine (Luvox, etc.)
- Meperidine (Demerol)
- Methadone (Dolophine, etc.)
- Levomilnacipran (Fetzima)
- Milnacipran (Savella)
- Paroxetine (Paxil, etc.)
- Propoxyphene*
- Sertraline (Zoloft)
- Tapentadol (Nucynta, etc.)
- Tetrabenazine (Xenazine)
- Tramadol (Ultram, etc.)
- Trazodone (Desyrel)
- Venlafaxine (Effexor)
- Vilazodone (Viibryd)
- Vortioxetine (Brintellix)
* Propoxyphene (Darvon) was withdrawn from the US market.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. For example, one study found no interaction when rasagiline and citalopram were given together. 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:
- Serotonergic Drug: 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.
- Linezolid: Tedizolid (Sivextro) does not appear to be a MAOI to a clinically important degree, so is unlikely to increase the risk of serotonin syndrome. Also, depending on the antibiogram, one could 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).