Erythromycin Ergotamine

Clinically important, potentially hazardous interactions with aprepitant, astemizole, carbamazepine, colchicine, cyclosporine, dihydroergotamine, ergot alkaloids, ergotamine, erythromycin, fluoxetine, fluvoxamine, methylprednisolone, methysergide, oral contraceptives, paroxetine, pimozide, prednisolone, rifampicin, sertraline, solifenacin, terfenadine, warfarin... 

Diphenhydramine hydrochloride, 3,173 Diphenoxylate hydrochloride, 7,149 Disulflram, 4, 168 Dobutamine hydrochloride, 8,139 Droperidol, 7,171 Echothiophate iodide, 3,233 Epinephrine, 7, 193 Ergotamine tartrate, 6,113 Erythromycin, 8,139 Erythromycin estolate, 1, 101 2, 573 Estradiol valerate, 4,192 Ethambutol hydrochloride, 7,231 Ethynodiol diacetate, 3,253 Fenoprofen calcium, 6,161 Flucytosine, 5,115 Fludrocortisone acetate, 3, 281 Fluorouracil, 2,221 Fluoxymesterone, 7,251 Fluphenazine enanthate, 2, 245 4,523 Fluphenazine hydrochloride, 2,263 4,518 Gluthethimide,5,139 Gramicidin, 8,179 Griseofulvin, 8,219 Halcinonide, 8,251 Halothane, 1, 119 2,573 Hexetidine, 7,277 Hydralazine hydrochloride, 8,283 Hydroflumethiazide, 7,297 Hydroxyprogesterone caproate, 4,209 Hydroxyzine dihydrochloride, 7,319 Iodipamide, 3,333 Isocarboxazid, 2, 295... 

Pregnancy (ergotamine s powerful uterine stimulant actions may cause fetal harm) hypersensitivity to ergot alkaloids peripheral vascular disease (eg, thromboangiitis obliterans, leutic arteritis, severe arteriosclerosis, thrombophlebitis, Raynaud s disease) hepatic or renal impairment severe pruritus coronary artery disease hypertension sepsis. The use of potent CYP3A4 inhibitors (ritonavir, nelfinavir, indinavir, erythromycin, clarithromycin, troleandomycin, ketoconazole, itraconazole) with dihydroergotamine is contraindicated. 

R. Ghali, et al., Erythromycin associated ergotamine intoxication Arteriographic and electrophysiologic analysis of a rare cause of severe ischemia of the lower extremities and associated in ischemic neuropathy. Ann. Vase. Surg. 7 291-296, 1993. 

The interaction of erythromycin with ergotamine or di-hydroergotamine can cause ergotism, sometimes leading to gangrene, by inhibition of the metabohsm of the ergo-peptides (74). 

HPI KO is a 57-year-old man with a history of migraine headaches and MTN who just completed a course of antibiotics for an upper respiratory infection. He had a severe migraine headache for which he took 10 tablets of ergotamine over 6 hours. He is presenting to the ambulatory care clinic with complaints of muscle cramps and numbness in his extremities. Medications Ergotamine 2 mg at onset of headache, then 1 mg every 30 minutes until headache resolution metoprolol and erythromycin for 10 days, KO has NKDA. 

Case Conclusion KO is experiencing peripheral vasospasm from an interaction between his ergotamine and the erythromycin. It is also recommended that KO not exceed 6 tablets of ergotamine per migraine attack or 10 tablets per week. Acute ergotism can be manifested when these agents are u d concurrently, manifesting as peripheral ischemia. Nitro-prusside IV may be required In more severe cases. 

Ergot toxicity can deveiop rapidiy in patients taking ergotamine or dihydroergotamine if they are given erythromycin or trolean-domycin. Three possibie cases of toxicity have occurred with clarithromycin, and one case has been reported with each of josamycin and oieandomycin. Toxicity is predicted to occur with midecamycin. No cases of toxicity appear to have been described with spiramycin, and none wouid be expected. There is no direct information about azithromycin but it would not be expected to interact. 

A woman who had regularly and uneventfully taken Migral (ergotamine tartrate 2 mg, cyclizine hydrochloride 50 mg, caffeine 100 mg) on a number of previous occasions, took one tablet during a course of treatment with erythromycin 250 mg every 6 hours. Within 2 days she developed severe ischaemic pain in her arms and legs during exercise, with a burning sensation in her feet and hands. When admitted to hospital 10 days later, her extremities were cool and cyanosed. Her pulse could not be detected in the lower limbs. ... 

Eight other cases of acute ergotism have been reported "" in which patients were taking ergotamine tartrate or dihydroergotamine and erythromycin. The reaction has been reported to develop within a few hours, but it may take several days to occur. " One case appeared to occur when the erythromycin was started 3 days after the last dose of dihydroergotamine. ... 

Lagier G, Castot A, Riboulet G, Boesh C. Un cas d ergotisme mineur semblant en rapport avec une potentiaUsation de I ergotamine par I elhylsuccinate d erythromycine. Therapie (1979)34,515-21. 

Collet AM, Moncharmont D, San Marco JL, Eissinger F, Pinot JJ, Laselve L. Ergotisme ia-trc e role de Tassociation tartrate d ergotamine-propionate d erythromycine. Sem Hop Pan.s(1982)58,1624-6. 

Examples of other substances that may contain more than 4 % impurities are dexamethasone sodium phosphate, ergotamine tartrate, erythromycin, codergocrine mesilate, cyanocobalamin, hydroxycobalamin, thiamine hydrochloride and ferrous fumarate. 

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