Drug-Drug

• Concurrent use with MAOIs ↑ risk of serious adverse reactions, including serotonin syndrome; MAOI use should be discontinued at least 14 days before/allow 14 days after discontinuing to start MAOIs.

• ↑ blood levels and risk of adverse reactions from desipramine and paroxetine ; ↓ dose of antidepressant and determine dose by clinical response.

• Concurrent therapy with strong or moderate inhibitors of the CYP3A4 enzyme system including aprepitant , atazanavir , clarithromycin , diltiazem , erythromycin , fluconazole , fosamprenavir , indinavir , itraconazole , ketoconazole , nefazodone , nelfinavir , ritonavir , saquinavir , telithromycin and verapamil ↑ risk of QT prolongation; careful monitoring recommended.

• Concurrent use with SSRIs or tricyclic antidepressants may result in serotonin syndrome.

• Avoid concurrent use with drugs that prolong QT interval together with drugs that are metabolized by CYP 2D6 including thioridazine and pimozide .

• When using with drugs that prolong QT interval and drugs that are moderate/strong inhibitors of CYP3A4 ECG monitoring is recommended.

• Concurrent use of drugs that are metabolized by CYP2D6 , especially those with narrow therapeutic indeces should be undertaken with caution, dose modifications or choosing an alternative agent may be necessary, including codeine and hydrocodone .

• ↑ blood levels and risk of toxicity/adverse reactions from desipramine (daily dose should not exceed 40 mg/day) or paroxetine (dose should not exceed 35 mg/day.

• ↑ blood levels and the risk of toxicity from digoxin , careful monitoring recommended.

• ↑ CNS depressant with other CNS depressants including antihistamines , some antidepressants , sedative/hypnotics and alcohol .