7 DRUG INTERACTIONS
Phenytoin is extensively bound to plasma proteins and is prone to competitive displacement. Phenytoin is primarily metabolized by the hepatic cytochrome P450 enzyme CYP2C9 and to a lesser extent by CYP2C19, and is particularly susceptible to inhibitory drug interactions because it is subject to saturable metabolism. Inhibition of metabolism may produce significant increases in circulating phenytoin concentrations and enhance the risk of drug toxicity. Monitoring of phenytoin serum levels is recommended when a drug interaction is suspected.
Phenytoin is a potent inducer of hepatic drug-metabolizing enzymes.
7.1 Drugs that Affect Phenytoin Concentrations
Table 2 includes commonly occurring drug interactions that affect phenytoin concentrations. However, this list is not intended to be inclusive or comprehensive. Individual prescribing information from relevant drugs should be consulted.
The addition or withdrawal of these agents in patients on phenytoin therapy may require an adjustment of the phenytoin dose to achieve optimal clinical outcome.
| Interacting Agent | Examples |
|---|---|
| Drugs that may increase phenytoin serum levels | |
| Antiepileptic drugs | Ethosuximide, felbamate, oxcarbazepine, methsuximide, topiramate |
| Azoles | Fluconazole, ketoconazole, itraconazole, miconazole, voriconazole |
| Antineoplastic agents | Capecitabine, fluorouracil |
| Antidepressants | Fluoxetine, fluvoxamine, sertraline |
| Gastric acid reducing agents | H2 antagonists (cimetidine), omeprazole |
| Sulfonamides | Sulfamethizole, sulfaphenazole, sulfadiazine, sulfamethoxazole-trimethoprim |
| Other | Acute alcohol intake, amiodarone, chloramphenicol, chlordiazepoxide, disulfiram, estrogen, fluvastatin, isoniazid, methylphenidate, phenothiazines, salicylates, ticlopidine, tolbutamide, trazodone, warfarin |
| Drugs that may decrease phenytoin serum levels | |
| Antacids* | Calcium carbonate, aluminum hydroxide, magnesium hydroxide Prevention or Management: Phenytoin and antacids should not be taken at the same time of day |
| Antineoplastic agents usually in combination | Bleomycin, carboplatin, cisplatin, doxorubicin, methotrexate |
| Antiviral agents | Fosamprenavir, nelfinavir, ritonavir |
| Antiepileptic drugs | Carbamazepine, vigabatrin |
| Other | Chronic alcohol abuse, diazepam, diazoxide, folic acid, reserpine, rifampin, St. John's wort†, sucralfate, theophylline |
| Drugs that may either increase or decrease phenytoin serum levels | |
| Antiepileptic drugs | Phenobarbital, valproate sodium, valproic acid |
7.2 Drugs Affected by Phenytoin
Table 3 includes commonly occurring drug interactions affected by phenytoin. However, this list is not intended to be inclusive or comprehensive. Individual drug package inserts should be consulted. The addition or withdrawal of phenytoin during concomitant therapy with these agents may require adjustment of the dose of these agents to achieve optimal clinical outcome.
| Interacting Agent | Examples |
|---|---|
| |
| Drugs whose efficacy is impaired by phenytoin | |
| Azoles | Fluconazole, ketoconazole, itraconazole, posaconazole, voriconazole |
| Antineoplastic agents | Irinotecan, paclitaxel, teniposide |
| Delavirdine | Phenytoin can substantially reduce the concentrations of delavirdine. This can lead to loss of virologic response and possible resistance [see Contraindications (4)]. |
| Neuromuscular blocking agents | Cisatracurium, pancuronium, rocuronium and vecuronium: resistance to the neuromuscular blocking action of the nondepolarizing neuromuscular blocking agents has occurred in patients chronically administered phenytoin. Whether or not phenytoin has the same effect on other non-depolarizing agents is unknown. Prevention or Management: Patients should be monitored closely for more rapid recovery from neuromuscular blockade than expected, and infusion rate requirements may be higher. |
| Warfarin | Increased and decreased PT/INR responses have been reported when phenytoin is coadministered with warfarin |
| Other | Corticosteroids, doxycycline, estrogens, furosemide, oral contraceptives, paroxetine, quinidine, rifampin, sertraline, theophylline, and vitamin D |
| Drugs whose level is decreased by phenytoin | |
| Antiepileptic drugs* | Carbamazepine, felbamate, lamotrigine, topiramate, oxcarbazepine, |
| Antilipidemic agents | Atorvastatin, fluvastatin, simvastatin |
| Antiviral agents | Efavirenz, lopinavir/ritonavir, indinavir, nelfinavir, ritonavir, saquinavir Fosamprenavir: phenytoin when given with fosamprenavir alone may decrease the concentration of amprenavir, the active metabolite. Phenytoin when given with the combination of fosamprenavir and ritonavir may increase the concentration of amprenavir |
| Calcium channel blockers | Nifedipine, nimodipine, nisoldipine, verapamil |
| Other | Albendazole (decreases active metabolite), chlorpropamide, clozapine, cyclosporine, digoxin, disopyramide, folic acid, methadone, mexiletine, praziquantel, quetiapine |
7.3 Drug Enteral Feeding/Nutritional Preparations Interaction
Literature reports suggest that patients who have received enteral feeding preparations and/or related nutritional supplements have lower than expected phenytoin serum levels. It is therefore suggested that phenytoin not be administered concomitantly with an enteral feeding preparation. More frequent serum phenytoin level monitoring may be necessary in these patients.