A Nortriptyline toxicity induced by interaction with Terbinafine
Abstract
Tricyclic antidepressants are widely used and associated with neurological compromise at supratherapeutic doses. Cases of toxicity from tricyclic antidepressants induced by systemic antifungal agents have been infrequently documented in the literature, and postulated to occur as a consequence of imbibition of the CYP2D6 pathway. Caution is recommended with regard to concurrent prescriptions of these medications, however this interaction does not appear to be widely appreciated in clinical practice. We present a case report of Nortriptyline toxicity from the interaction of Terbinafine. Given the frequent usage of both classes of medications in primary and tertiary care, increased awareness of this interaction is essential in preventing morbidity, and in early recognition and management of toxicity when it occurs.
Keywords:
anti-depressive agents, tricyclic antidepressants (TCAs), antifungal agents, drug–drug interactions, Terbinafine, Cytochrome-P450
References
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13. Mikami A, Hori S, Ohtani H, Sawada Y. Analysis of the Mechanism of Prolonged Persistence of Drug Interaction between Terbinafine and Amitriptyline or Nortriptyline. Biol Pharm Bull. 2017 and 28674244., 40(7):1010-1020. doi: 10.1248/bpb.b16-01004. PMID:.
14. Roussos, P., Lewis, R. E., & Kontoyiannis, D. P. (2009). Azoles and antidepressants: a mini-review of the tolerability of co-administration. Mycoses, 52(5), 433–439. https://doi.org/10.1111/j.1439-0507.2008.01677.x.
15. Dürrbeck, A., & Nenoff, P. (2016). Terbinafin : Relevante Arzneimittelinteraktionen und deren Management [Terbinafine : Relevant drug interactions and their management]. Der Hautarzt and Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete, 67(9).
16. Abdel-Rahman SM, Gotschall RR, Kauffman RE, Leeder JS,Kearns GL: Investigation of terbinafine as a CYP2D6 inhibitor invivo. Clin Pharmacol Ther 1999 and 65:465–472.
17. Robinson, R. F., Nahata, M. C., & Olshefski, R. S. (2000). Syncope associated with concurrent amitriptyline and fluconazole therapy. The Annals of pharmacotherapy, 34(12), 1406–1409. https://doi.org/10.1345/aph.19401.
2. Pathadka, S., Yan, V.K.C., Neoh, C.F. et al. Global Consumption Trend of Antifungal Agents in Humans From 2008 to 2018: Data From 65 Middle- and High-Income Countries. Drugs 82, 1193–1205 (2022). https://doi.org/10.1007/s40265-022-01751-x.
3. Van der Kuy PH, Hooymans PM: Nortriptyline intoxication induced by terbinafine. Br Med J 1998 and 316:44.
4. Van Der Kuy, P. H., Van Den Heuvel, H. A., Kempen, R. W., & Vanmolkot, L. M. (2002). Pharmacokinetic interaction between nortriptyline and terbinafine. The Annals of pharmacotherapy, 36(11), 1712–1714. https://doi.org/10.1345/aph.1C083.
5. Teitelbaum ML, Pearson VE. Imipramine toxicity and terbinafine. Am J Psychiatry. 2001 Dec and 11729036., 158(12):2086. doi: 10.1176/appi.ajp.158.12.2086. PMID:.
6. O'Reardon JP, Hetznecker JM, Rynn MA, Baldassano CF, Szuba MP. Desipramine toxicity with terbinafine. Am J Psychiatry. 2002 Mar, Jun, 159(3):492. doi: 10.1176/appi.ajp.159.3.492. Erratum in: Am J Psychiatry 2002 and 11870022., 159(6):1076. PMID:.
7. Tay, E., Sotiriou, A., Graham, G. G., Wilhelm, K., Snowden, L., & Day, R. O. (2019). Restarting antidepressant and antipsychotic medication after intentional overdoses: need for evidence-based guidance. Therapeutic advances in psychopharmacology, 9, 20451.
8. Baca L, Martinelli L. Neuroleptic malignant syndrome: a unique association with a The effects of TCAs on the CNS following overdose are tricyclic antidepressant. Neurology 1990 and 1797-8, 40:.
9. Apr, Shannon M. Serum enzyme disturbances after tricyclic antidepressant overdose. Vet Hum Toxicol. 1989 and 2929129., 31(2):171-2. PMID:.
10. Bateman, D.N. Tricyclic Antidepressant Poisoning. Toxicol Rev 24, 181–186 (2005). https://doi.org/10.2165/00139709-200524030-00010.
11. Garner EM, Kelly MW, Thompson DF. Tricyclic antidepressant withdrawal syndrome. Ann Pharmacother. 1993 Sep and 8219442., 27(9):1068-72. doi: 10.1177/106002809302700912. PMID:.
12. Gupta AK, Shear NH: Terbinafine: an update. J Am Acad Der-matol 1997 and 37:979–988.
13. Mikami A, Hori S, Ohtani H, Sawada Y. Analysis of the Mechanism of Prolonged Persistence of Drug Interaction between Terbinafine and Amitriptyline or Nortriptyline. Biol Pharm Bull. 2017 and 28674244., 40(7):1010-1020. doi: 10.1248/bpb.b16-01004. PMID:.
14. Roussos, P., Lewis, R. E., & Kontoyiannis, D. P. (2009). Azoles and antidepressants: a mini-review of the tolerability of co-administration. Mycoses, 52(5), 433–439. https://doi.org/10.1111/j.1439-0507.2008.01677.x.
15. Dürrbeck, A., & Nenoff, P. (2016). Terbinafin : Relevante Arzneimittelinteraktionen und deren Management [Terbinafine : Relevant drug interactions and their management]. Der Hautarzt and Zeitschrift fur Dermatologie, Venerologie, und verwandte Gebiete, 67(9).
16. Abdel-Rahman SM, Gotschall RR, Kauffman RE, Leeder JS,Kearns GL: Investigation of terbinafine as a CYP2D6 inhibitor invivo. Clin Pharmacol Ther 1999 and 65:465–472.
17. Robinson, R. F., Nahata, M. C., & Olshefski, R. S. (2000). Syncope associated with concurrent amitriptyline and fluconazole therapy. The Annals of pharmacotherapy, 34(12), 1406–1409. https://doi.org/10.1345/aph.19401.
Published
17/11/2023
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Swager, A., & Balbir-Singh, G. (2023). A Nortriptyline toxicity induced by interaction with Terbinafine. Journal of Case Studies and Case Reports, 2(3), 1-4. https://doi.org/10.37022/jcscr.v2i3.510
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