Brief Answer:
List of medications

Detailed Answer:
Hello and welcome,

That is a lot of medication, especially all of the anti depressive/anti anxiety medication, and there are increased risks of side effects when all of these are taken together, but it is not necessarily fatal. Other considerations need to be taken into consideration such as how long a patient has been on each and whether they are sensitive to certain classes of meds, and underlying health problems.

Is there further information you would like me to provide you with?

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Brief Answer:
More information

Detailed Answer:
I am so sorry to hear this. What a painful loss.

I'll provide additional information.

Remeron and Mirtazapine are the same medication (mirtazapine is the generic of Remeron).

Venlafaxine is the generic of Effexor, so those are the same medication also.


I am not sure why (or if) your nephew took both of each medication at the same time. Perhaps one of each was an older prescription that he had used up and then was on the generic of it.

If he was taking both the brand name and the generic of each, then yes, serotonin syndrome could be a consideration.

All of his medications, except for the Lisinopril, can cause central nervous system (CNS) depression meaning they can cause a person to be slowed down, sedated or sleepy, and in overdose, can slow or stop respirations because of shutting down the brain.

I'll list what the meds he was taking are commonly used for if that will help you:
Neurontin (gabapentin): this is an anti seizure medication that is also used for chronic pain as well as sometimes for psychiatric reasons.

Remeron (mirtazapine): antidepressant

Effexor (venlafaxine): antidepressant

Klonopin (clonazapam): an anti-anxiety med in the family of Valium (i.e. benzodiazepine). Used for anxiety, and sometimes for muscle spasms, sedation, sleep, alcohol withdrawal and to prevent seizures.

Clonidine: an older anti-high blood pressure (antihypertensive) drug used for many purposes including alcohol withdrawal and anxiety.

Ambien (zolpidem): for sleep

Lisinopril: a blood pressure medication (antihypertensive)

Topomax (topirimate): an antiseizure medicaiton. Also used for migraines, and weight loss



This will be lengthy, but I am going to copy and paste each possible drug interaction from the Lexicomp Drug Interaction data base which is used by physicians. Information that I am adding to this will be in brackets like this [ ].

-----------------
[The following interactions applies to if the Ambien was sublingual (i.e. under the tongue) rather than swallowed. These interactions are with
Ambien (zolpidem) and
Neurontin (gabapentin), Remeron (mirtazapine), Klonopin (clonazapam), Clonodine, and Topamax]

Title Zolpidem [Ambien] with CNS Depressants

Dependencies

Brand Name: A dose reduction is recommended for Intermezzo brand sublingual zolpidem (applies to men only) but is not applicable to the other zolpidem products.

Risk Rating D: Consider therapy modification

Summary CNS Depressants may enhance the CNS depressant effect of Zolpidem. Severity Major Reliability Rating Fair: Reported in the prescribing information

Patient Management When possible, avoid the concurrent use of zolpidem with other CNS depressants. If concurrent use can not be avoided, consider using a lower dose of the other CNS depressant when possible. The use of zolpidem with alcohol is specifically not recommended. The use of Intermezzo brand zolpidem sublingual tablets with other sedative-hypnotics at bedtime or in the middle of the night is also specifically not recommended. A reduced Intermezzo brand sublingual zolpidem adult dose of 1.75 mg is recommended for men using sublingual zolpidem who are also receiving other CNS depressants. No specific dose reduction is recommended for women using Intermezzo together with other CNS depressants. All patients using such a combination should be strongly cautioned about the potential for prolonged and/or excessive CNS depression, and such patients should be followed closely for evidence of excessive CNS depression and/or psychomotor impairment.

CNS Depressants Interacting Members Acrivastine, Afloqualone, Alcohol (Ethyl), Alfentanil, ALPRAZolam, Amisulpride, Amitriptyline, Amobarbital, Amoxapine, ARIPiprazole, ARIPiprazole Lauroxil, Asenapine, Baclofen, Benperidol, Benzhydrocodone, Bilastine, Blonanserin, Brexpiprazole, Brimonidine (Ophthalmic), Brivaracetam, Bromazepam, Bromperidol, Brompheniramine, Buclizine, Buprenorphine, BusPIRone, Butabarbital, Butalbital, Butorphanol, CarBAMazepine, Carbinoxamine, Cariprazine, Carisoprodol, Cetirizine (Systemic), Chloral Betaine, Chloral Hydrate, ChlordiazePOXIDE, Chlormethiazole, Chlorpheniramine, ChlorproMAZINE, Chlorzoxazone, Cinnarizine, Clemastine, CloBAZam, ClomiPRAMINE, ClonazePAM, CloNIDine, Clorazepate, Clothiapine, CloZAPine, Codeine, Cyclizine, Cyclobenzaprine, Cyproheptadine, Dantrolene, Desflurane, Desipramine, Desloratadine, Deutetrabenazine, Dexbrompheniramine, Dexchlorpheniramine, DiazePAM, Difenoxin, Dihydrocodeine, DimenhyDRINATE, Dimethindene (Systemic), DiphenhydrAMINE (Systemic), DiphenhydrAMINE (Topical), Diphenoxylate, Dosulepin, Doxepin (Systemic), Doxepin (Topical), Doxylamine, Droperidol, Ebastine, Efavirenz, Emedastine (Systemic), Entacapone, Eperisone, Estazolam, Eszopiclone, Ethosuximide, Ethotoin, Ethyl Loflazepate, Etizolam, Ezogabine, Felbamate, FentaNYL, Fexofenadine, Flibanserin, Flunarizine, Flunitrazepam, Flupentixol, FluPHENAZine, Flurazepam, Fosphenytoin, Gabapentin, Gabapentin Enacarbil, Glutethimide, GuanFACINE, Haloperidol, Halothane, Heroin, HYDROcodone, HYDROmorphone, HydrOXYzine, Iloperidone, Imipramine, Isoflurane, Ketamine, Ketotifen (Systemic), LamoTRIgine, LevETIRAcetam, Levocetirizine, Levorphanol, Lofepramine, Loprazolam, Loratadine, LORazepam, Lormetazepam, Loxapine, Lurasidone, Maprotiline, Meclizine, Melitracen [INT], Meperidine, Meprobamate, Meptazinol, Mequitazine, Metaxalone, Methadone, Methocarbamol, Methohexital, Methotrimeprazine, Methoxyflurane, Methsuximide, Mianserin, Midazolam, Mirtazapine, Molindone, Morphine (Liposomal), Morphine (Systemic), Moxonidine, Nalbuphine, Nalfurafine, Nefopam, Nitrazepam, Nitrous Oxide, Nordazepam, Nortriptyline, OLANZapine, Olopatadine (Systemic), Opium, Opium Tincture, Orphenadrine, Oxatomide, Oxazepam, Oxomemazine, OxyCODONE, OxyMORphone, Paliperidone, Paraldehyde, Paregoric, Pentazocine, PENTobarbital, Perampanel, Periciazine, Perphenazine, Pheniramine, PHENobarbital, Phenyltoloxamine, Phenytoin, Pholcodine, Pimozide, Pipamperone [INT], Pipotiazine, Pizotifen, Pomalidomide, Prazepam, Pregabalin, Primidone, Prochlorperazine, Promazine, Promethazine, Propofol, Protriptyline, Pyrilamine (Systemic), Quazepam, QUEtiapine, Ramelteon, Remifentanil, Reserpine, Rilmenidine, RisperiDONE, Rupatadine, Scopolamine (Ophthalmic), Scopolamine (Systemic), Secobarbital, Sevoflurane, Sodium Oxybate, Stiripentol, SUFentanil, Sulpiride, Suvorexant, Tapentadol, Tasimelteon, Temazepam, Tetrabenazine, Thalidomide, Thiopental, Thioridazine, Thiothixene, Thonzylamine, TiaGABine, TiZANidine, Tofisopam, Tolcapone, Topiramate, TraMADol, Triazolam, Trifluoperazine, Trimeprazine, Trimipramine, Triprolidine, Valerian, Vigabatrin, Zaleplon, Ziconotide, Ziprasidone, Zolpidem, Zonisamide, Zopiclone, Zuclopenthixol

Discussion The prescribing information for both the sublingual and oral zolpidem tablets caution that concurrent use with other CNS depressants may result in enhanced CNS depression and may require dose adjustments of the other CNS depressant and/or zolpidem.1,2,3 Further, the prescribing information for the Intermezzo brand zolpidem sublingual tablet recommends a dose reduction for men (from 3.5 mg to 1.75 mg) when used with other CNS depressants. Though all zolpidem products acknowledge that dose adjustments may be required with other CNS depressants, the Intermezzo brand product specifically recommends avoiding concurrent use of other sedative-hypnotics at bedtime or in the middle of the night.1 Conversely, the prescribing information for the other zolpidem products do not specifically recommend avoiding use with CNS depressants at bedtime (other than alcohol, which is generally not recommended to be used with zolpidem).2,3

Concurrent use of zolpidem with other CNS depressants has been associated with greater psychomotor impairment, next-day driving impairment, and an increased risk for complex behaviors such as “sleep driving”, etc.1,2,3

The specific mechanism for this specific interaction appears to be additive or synergistic CNS depressant effects.

Footnotes

1. Prescribing information. Intermezzo (zolpidem). Point XXXXXXX CA: Transcept Pharmaceuticals, Inc., November 2011.

2. Prescribing information. Edluar (zolpidem). Somerset, NJ: XXXXXXX Pharmaceuticals Inc., 10/10.

3. Prescribing information. Ambien (zolpidem). Bridgewater, NJ: sanofi-aventis U.S. LLC, August 2010.

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[This next article is on the interaction of Effexor and Clonidine]

Title Alpha2-Agonists / Serotonin/Norepinephrine Reuptake Inhibitors

Risk Rating C: Monitor therapy

Summary Serotonin/Norepinephrine Reuptake Inhibitors may diminish the antihypertensive effect of Alpha2-Agonists. Severity Moderate Reliability Rating Fair

Patient Management Monitor clinical response to alpha2-agonist therapy closely, as response (particularly blood pressure-lowering) may be minimized with concurrent use of a serotonin/norepinephrine reuptake inhibitor.

Alpha2-Agonists Interacting Members Brimonidine (Ophthalmic), CloNIDine, Dexmedetomidine, GuanFACINE, Lofexidine, Methyldopa, Moxonidine, Rilmenidine, TiZANidine
Exception Apraclonidine

Serotonin/Norepinephrine Reuptake Inhibitors Interacting Members Desvenlafaxine, DULoxetine, Levomilnacipran, Milnacipran, Venlafaxine

Discussion Milnacipran, a serotonin/norepinephrine reuptake inhibitor (SNRI), prescribing information cautions that milnacipran may interfere with the antihypertensive actions of clonidine, an alpha2-agonist, due to milnacipran's inhibition of norepinephrine uptake.1 Though a dual inhibitor of serotonin and norepinephrine reuptake, milnacipran's norepinephrine effects are reportedly several-fold greater than its effects on serotonin. Additionally, despite a lack of specific data regarding a possible SNRI -- alpha2-agonist interaction, increased blood pressure and heart rate are known adverse effects of both milnacipran and other SNRIs,1,2,3,4 providing some basis for at least increasing monitoring during concurrent use with an alpha2-agonist.

Footnotes

1. Prescribing information. Savella (milnacipran). New York, NY: Forest Laboratories, Inc., January 2009.

2. Prescribing information. Pristiq (desvenlafaxine). XXXXXXX PA: Wyeth Pharmaceuticals Inc., 04/08.

3. Prescribing information. Effexor XR (venlafaxine). XXXXXXX PA: Wyeth Pharmaceuticals Inc., 11/08.

4. Prescribing information. Cymbalta (duloxetine). XXXXXXX IN: XXXXXXX XXXXXXX and Company, December 2008.

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[The next article is on Clonidine and medications that include Klonopin, Neurontin, and Topamax]

Title CNS Depressants / CNS Depressants

Risk Rating C: Monitor therapy

Summary CNS Depressants may enhance the adverse/toxic effect of other CNS Depressants. Severity Moderate Reliability Rating Good

Patient Management The concomitant use of two or more drugs that have the potential to depress CNS function (either as a therapeutic intention or a side effect) is often clinically appropriate. However, it is important to recognize that the risk of unwanted effects may increase with such use. Consider the duration of CNS depressant use and each patient's response (particularly tolerance to CNS depressant effects) when selecting additional agents and their doses. Monitor for additive CNS-depressant effects whenever two or more CNS depressants are concomitantly used. Advise patients to avoid any unprescribed, illicit, or recreational use of other CNS depressants.

CNS Depressants Interacting Members Acrivastine, Afloqualone, Alcohol (Ethyl), Alfentanil, ALPRAZolam, Amisulpride, Amitriptyline, Amobarbital, Amoxapine, ARIPiprazole, ARIPiprazole Lauroxil, Asenapine, Baclofen, Benperidol, Benzhydrocodone, Bilastine, Blonanserin, Brexpiprazole, Brimonidine (Ophthalmic), Brivaracetam, Bromazepam, Bromperidol, Brompheniramine, Buclizine, Buprenorphine, BusPIRone, Butabarbital, Butalbital, Butorphanol, CarBAMazepine, Carbinoxamine, Cariprazine, Carisoprodol, Cetirizine (Systemic), Chloral Betaine, Chloral Hydrate, ChlordiazePOXIDE, Chlormethiazole, Chlorpheniramine, ChlorproMAZINE, Chlorzoxazone, Cinnarizine, Clemastine, CloBAZam, ClomiPRAMINE, ClonazePAM, CloNIDine, Clorazepate, Clothiapine, CloZAPine, Codeine, Cyclizine, Cyclobenzaprine, Cyproheptadine, Dantrolene, Desflurane, Desipramine, Desloratadine, Deutetrabenazine, Dexbrompheniramine, Dexchlorpheniramine, DiazePAM, Difenoxin, Dihydrocodeine, DimenhyDRINATE, Dimethindene (Systemic), DiphenhydrAMINE (Systemic), DiphenhydrAMINE (Topical), Diphenoxylate, Dosulepin, Doxepin (Systemic), Doxepin (Topical), Doxylamine, Droperidol, Ebastine, Efavirenz, Emedastine (Systemic), Entacapone, Eperisone, Estazolam, Eszopiclone, Ethosuximide, Ethotoin, Ethyl Loflazepate, Etizolam, Ezogabine, Felbamate, FentaNYL, Fexofenadine, Flibanserin, Flunarizine, Flunitrazepam, Flupentixol, FluPHENAZine, Flurazepam, Fosphenytoin, Gabapentin, Gabapentin Enacarbil, Glutethimide, GuanFACINE, Haloperidol, Halothane, Heroin, HYDROcodone, HYDROmorphone, HydrOXYzine, Iloperidone, Imipramine, Isoflurane, Ketamine, Ketotifen (Systemic), LamoTRIgine, LevETIRAcetam, Levocetirizine, Levorphanol, Lofepramine, Loprazolam, Loratadine, LORazepam, Lormetazepam, Loxapine, Lurasidone, Maprotiline, Meclizine, Melitracen [INT], Meperidine, Meprobamate, Meptazinol, Mequitazine, Metaxalone, Methadone, Methocarbamol, Methohexital, Methotrimeprazine, Methoxyflurane, Methsuximide, Mianserin, Midazolam, Mirtazapine, Molindone, Morphine (Liposomal), Morphine (Systemic), Moxonidine, Nalbuphine, Nalfurafine, Nefopam, Nitrazepam, Nitrous Oxide, Nordazepam, Nortriptyline, OLANZapine, Olopatadine (Systemic), Opium, Opium Tincture, Orphenadrine, Oxatomide, Oxazepam, Oxomemazine, OxyCODONE, OxyMORphone, Paliperidone, Paraldehyde, Paregoric, Pentazocine, PENTobarbital, Perampanel, Periciazine, Perphenazine, Pheniramine, PHENobarbital, Phenyltoloxamine, Phenytoin, Pholcodine, Pimozide, Pipamperone [INT], Pipotiazine, Pizotifen, Pomalidomide, Prazepam, Pregabalin, Primidone, Prochlorperazine, Promazine, Promethazine, Propofol, Protriptyline, Pyrilamine (Systemic), Quazepam, QUEtiapine, Ramelteon, Remifentanil, Reserpine, Rilmenidine, RisperiDONE, Rupatadine, Scopolamine (Ophthalmic), Scopolamine (Systemic), Secobarbital, Sevoflurane, Sodium Oxybate, Stiripentol, SUFentanil, Sulpiride, Suvorexant, Tapentadol, Tasimelteon, Temazepam, Tetrabenazine, Thalidomide, Thiopental, Thioridazine, Thiothixene, Thonzylamine, TiaGABine, TiZANidine, Tofisopam, Tolcapone, Topiramate, TraMADol, Triazolam, Trifluoperazine, Trimeprazine, Trimipramine, Triprolidine, Valerian, Vigabatrin, Zaleplon, Ziconotide, Ziprasidone, Zolpidem, Zonisamide, Zopiclone, Zuclopenthixol

Discussion Each of the drugs listed in this monograph is capable of depressing the function of the central nervous system (CNS). Such effects may include, but are not limited to, ataxia, confusion, drowsiness, respiratory depression, and weakness.1 Concomitant use of two or more of these drugs may increase the risks associated with CNS depression. Caution is warranted.

Footnotes

1. Worthley LI, “Clinical Toxicology: Part I. Diagnosis and Management of Common Drug Overdosage,” Crit Care Resusc, 2002, 4(3):192-215. [PubMed 0000]

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[The next is on Effexor with Remeron]

Title Serotonin Modulators / Serotonin Modulators

Risk Rating C: Monitor therapy

Summary Serotonin Modulators may enhance the adverse/toxic effect of other Serotonin Modulators. The development of serotonin syndrome may occur. Severity Major Onset Rapid Reliability Rating Fair

Patient Management The concomitant use of agents that enhance serotonin activity should be undertaken with great caution. Patients should be monitored for the development of serotonin toxicity/serotonin syndrome during such therapy.

Serotonin Modulators Interacting Members 5-Hydroxytryptophan, Almotriptan, Amitriptyline, Amoxapine, Bromocriptine, BusPIRone, Cabergoline, Citalopram, ClomiPRAMINE, Cyclobenzaprine, Dapoxetine, Desipramine, Desvenlafaxine, Dextromethorphan, Dihydroergotamine, Dosulepin, Doxepin (Systemic), Doxepin (Topical), DULoxetine, Eletriptan, Ergoloid Mesylates, Ergonovine, Ergotamine, Escitalopram, FentaNYL, FLUoxetine, FluvoxaMINE, Frovatriptan, Imipramine, Isocarboxazid, Levomilnacipran, Linezolid, Lithium, Lofepramine, Lorcaserin, Maprotiline, Melitracen [INT], Meperidine, Methadone, Methylene Blue, Methylergonovine, Milnacipran, Mirtazapine, Moclobemide, Naratriptan, Nefazodone, Nortriptyline, PARoxetine, Pergolide, Phenelzine, Procarbazine, Promethazine, Protriptyline, Rasagiline, Rizatriptan, Safinamide, SAMe (S-adenosylmethionine), Selegiline, Sertraline, St John's Wort, SUMAtriptan, Tapentadol, TraMADol, Tranylcypromine, TraZODone, Trimipramine, Tryptophan, Venlafaxine, Vilazodone, Vortioxetine, ZOLMitriptan
Exceptions Nicergoline, Tedizolid

Discussion Many drugs possess an ability to enhance serotonin activity, and are so used in a variety of disease states. The concomitant use of 2 or more of these agents may increase the risk of toxic effects due to central serotonergic overstimulation. These toxic effects may affect autonomic, neuromuscular, and cognitive function, and are termed “serotonin toxicity” or “serotonin syndrome” under some circumstances.1,2

Footnotes

1. Dunkley EJ, Isbister GK, Sibbritt D, XXXXXXX AH, Whyte IM. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM. 2003;96(9):635-642. [PubMed 0000]

2. Sternbach H. The serotonin syndrome. Am J Psychiatry. 1991;148(6):705-713. [PubMed 0000]

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[The next is for the combination of Klopin and Neurontin or Topamax or Remeron]

Title CNS Depressants / CNS Depressants

Risk Rating C: Monitor therapy

Summary CNS Depressants may enhance the adverse/toxic effect of other CNS Depressants. Severity Moderate Reliability Rating Good

Patient Management The concomitant use of two or more drugs that have the potential to depress CNS function (either as a therapeutic intention or a side effect) is often clinically appropriate. However, it is important to recognize that the risk of unwanted effects may increase with such use. Consider the duration of CNS depressant use and each patient's response (particularly tolerance to CNS depressant effects) when selecting additional agents and their doses. Monitor for additive CNS-depressant effects whenever two or more CNS depressants are concomitantly used. Advise patients to avoid any unprescribed, illicit, or recreational use of other CNS depressants.

CNS Depressants Interacting Members Acrivastine, Afloqualone, Alcohol (Ethyl), Alfentanil, ALPRAZolam, Amisulpride, Amitriptyline, Amobarbital, Amoxapine, ARIPiprazole, ARIPiprazole Lauroxil, Asenapine, Baclofen, Benperidol, Benzhydrocodone, Bilastine, Blonanserin, Brexpiprazole, Brimonidine (Ophthalmic), Brivaracetam, Bromazepam, Bromperidol, Brompheniramine, Buclizine, Buprenorphine, BusPIRone, Butabarbital, Butalbital, Butorphanol, CarBAMazepine, Carbinoxamine, Cariprazine, Carisoprodol, Cetirizine (Systemic), Chloral Betaine, Chloral Hydrate, ChlordiazePOXIDE, Chlormethiazole, Chlorpheniramine, ChlorproMAZINE, Chlorzoxazone, Cinnarizine, Clemastine, CloBAZam, ClomiPRAMINE, ClonazePAM, CloNIDine, Clorazepate, Clothiapine, CloZAPine, Codeine, Cyclizine, Cyclobenzaprine, Cyproheptadine, Dantrolene, Desflurane, Desipramine, Desloratadine, Deutetrabenazine, Dexbrompheniramine, Dexchlorpheniramine, DiazePAM, Difenoxin, Dihydrocodeine, DimenhyDRINATE, Dimethindene (Systemic), DiphenhydrAMINE (Systemic), DiphenhydrAMINE (Topical), Diphenoxylate, Dosulepin, Doxepin (Systemic), Doxepin (Topical), Doxylamine, Droperidol, Ebastine, Efavirenz, Emedastine (Systemic), Entacapone, Eperisone, Estazolam, Eszopiclone, Ethosuximide, Ethotoin, Ethyl Loflazepate, Etizolam, Ezogabine, Felbamate, FentaNYL, Fexofenadine, Flibanserin, Flunarizine, Flunitrazepam, Flupentixol, FluPHENAZine, Flurazepam, Fosphenytoin, Gabapentin, Gabapentin Enacarbil, Glutethimide, GuanFACINE, Haloperidol, Halothane, Heroin, HYDROcodone, HYDROmorphone, HydrOXYzine, Iloperidone, Imipramine, Isoflurane, Ketamine, Ketotifen (Systemic), LamoTRIgine, LevETIRAcetam, Levocetirizine, Levorphanol, Lofepramine, Loprazolam, Loratadine, LORazepam, Lormetazepam, Loxapine, Lurasidone, Maprotiline, Meclizine, Melitracen [INT], Meperidine, Meprobamate, Meptazinol, Mequitazine, Metaxalone, Methadone, Methocarbamol, Methohexital, Methotrimeprazine, Methoxyflurane, Methsuximide, Mianserin, Midazolam, Mirtazapine, Molindone, Morphine (Liposomal), Morphine (Systemic), Moxonidine, Nalbuphine, Nalfurafine, Nefopam, Nitrazepam, Nitrous Oxide, Nordazepam, Nortriptyline, OLANZapine, Olopatadine (Systemic), Opium, Opium Tincture, Orphenadrine, Oxatomide, Oxazepam, Oxomemazine, OxyCODONE, OxyMORphone, Paliperidone, Paraldehyde, Paregoric, Pentazocine, PENTobarbital, Perampanel, Periciazine, Perphenazine, Pheniramine, PHENobarbital, Phenyltoloxamine, Phenytoin, Pholcodine, Pimozide, Pipamperone [INT], Pipotiazine, Pizotifen, Pomalidomide, Prazepam, Pregabalin, Primidone, Prochlorperazine, Promazine, Promethazine, Propofol, Protriptyline, Pyrilamine (Systemic), Quazepam, QUEtiapine, Ramelteon, Remifentanil, Reserpine, Rilmenidine, RisperiDONE, Rupatadine, Scopolamine (Ophthalmic), Scopolamine (Systemic), Secobarbital, Sevoflurane, Sodium Oxybate, Stiripentol, SUFentanil, Sulpiride, Suvorexant, Tapentadol, Tasimelteon, Temazepam, Tetrabenazine, Thalidomide, Thiopental, Thioridazine, Thiothixene, Thonzylamine, TiaGABine, TiZANidine, Tofisopam, Tolcapone, Topiramate, TraMADol, Triazolam, Trifluoperazine, Trimeprazine, Trimipramine, Triprolidine, Valerian, Vigabatrin, Zaleplon, Ziconotide, Ziprasidone, Zolpidem, Zonisamide, Zopiclone, Zuclopenthixol

Discussion Each of the drugs listed in this monograph is capable of depressing the function of the central nervous system (CNS). Such effects may include, but are not limited to, ataxia, confusion, drowsiness, respiratory depression, and weakness.1 Concomitant use of two or more of these drugs may increase the risks associated with CNS depression. Caution is warranted.

Footnotes

1. Worthley LI, “Clinical Toxicology: Part I. Diagnosis and Management of Common Drug Overdosage,” Crit Care Resusc, 2002, 4(3):192-215. [PubMed 0000]

------------

[The next is Neurontin and Topamax]

Title CNS Depressants / CNS Depressants

Risk Rating C: Monitor therapy

Summary CNS Depressants may enhance the adverse/toxic effect of other CNS Depressants. Severity Moderate Reliability Rating Good

Patient Management The concomitant use of two or more drugs that have the potential to depress CNS function (either as a therapeutic intention or a side effect) is often clinically appropriate. However, it is important to recognize that the risk of unwanted effects may increase with such use. Consider the duration of CNS depressant use and each patient's response (particularly tolerance to CNS depressant effects) when selecting additional agents and their doses. Monitor for additive CNS-depressant effects whenever two or more CNS depressants are concomitantly used. Advise patients to avoid any unprescribed, illicit, or recreational use of other CNS depressants.

CNS Depressants Interacting Members Acrivastine, Afloqualone, Alcohol (Ethyl), Alfentanil, ALPRAZolam, Amisulpride, Amitriptyline, Amobarbital, Amoxapine, ARIPiprazole, ARIPiprazole Lauroxil, Asenapine, Baclofen, Benperidol, Benzhydrocodone, Bilastine, Blonanserin, Brexpiprazole, Brimonidine (Ophthalmic), Brivaracetam, Bromazepam, Bromperidol, Brompheniramine, Buclizine, Buprenorphine, BusPIRone, Butabarbital, Butalbital, Butorphanol, CarBAMazepine, Carbinoxamine, Cariprazine, Carisoprodol, Cetirizine (Systemic), Chloral Betaine, Chloral Hydrate, ChlordiazePOXIDE, Chlormethiazole, Chlorpheniramine, ChlorproMAZINE, Chlorzoxazone, Cinnarizine, Clemastine, CloBAZam, ClomiPRAMINE, ClonazePAM, CloNIDine, Clorazepate, Clothiapine, CloZAPine, Codeine, Cyclizine, Cyclobenzaprine, Cyproheptadine, Dantrolene, Desflurane, Desipramine, Desloratadine, Deutetrabenazine, Dexbrompheniramine, Dexchlorpheniramine, DiazePAM, Difenoxin, Dihydrocodeine, DimenhyDRINATE, Dimethindene (Systemic), DiphenhydrAMINE (Systemic), DiphenhydrAMINE (Topical), Diphenoxylate, Dosulepin, Doxepin (Systemic), Doxepin (Topical), Doxylamine, Droperidol, Ebastine, Efavirenz, Emedastine (Systemic), Entacapone, Eperisone, Estazolam, Eszopiclone, Ethosuximide, Ethotoin, Ethyl Loflazepate, Etizolam, Ezogabine, Felbamate, FentaNYL, Fexofenadine, Flibanserin, Flunarizine, Flunitrazepam, Flupentixol, FluPHENAZine, Flurazepam, Fosphenytoin, Gabapentin, Gabapentin Enacarbil, Glutethimide, GuanFACINE, Haloperidol, Halothane, Heroin, HYDROcodone, HYDROmorphone, HydrOXYzine, Iloperidone, Imipramine, Isoflurane, Ketamine, Ketotifen (Systemic), LamoTRIgine, LevETIRAcetam, Levocetirizine, Levorphanol, Lofepramine, Loprazolam, Loratadine, LORazepam, Lormetazepam, Loxapine, Lurasidone, Maprotiline, Meclizine, Melitracen [INT], Meperidine, Meprobamate, Meptazinol, Mequitazine, Metaxalone, Methadone, Methocarbamol, Methohexital, Methotrimeprazine, Methoxyflurane, Methsuximide, Mianserin, Midazolam, Mirtazapine, Molindone, Morphine (Liposomal), Morphine (Systemic), Moxonidine, Nalbuphine, Nalfurafine, Nefopam, Nitrazepam, Nitrous Oxide, Nordazepam, Nortriptyline, OLANZapine, Olopatadine (Systemic), Opium, Opium Tincture, Orphenadrine, Oxatomide, Oxazepam, Oxomemazine, OxyCODONE, OxyMORphone, Paliperidone, Paraldehyde, Paregoric, Pentazocine, PENTobarbital, Perampanel, Periciazine, Perphenazine, Pheniramine, PHENobarbital, Phenyltoloxamine, Phenytoin, Pholcodine, Pimozide, Pipamperone [INT], Pipotiazine, Pizotifen, Pomalidomide, Prazepam, Pregabalin, Primidone, Prochlorperazine, Promazine, Promethazine, Propofol, Protriptyline, Pyrilamine (Systemic), Quazepam, QUEtiapine, Ramelteon, Remifentanil, Reserpine, Rilmenidine, RisperiDONE, Rupatadine, Scopolamine (Ophthalmic), Scopolamine (Systemic), Secobarbital, Sevoflurane, Sodium Oxybate, Stiripentol, SUFentanil, Sulpiride, Suvorexant, Tapentadol, Tasimelteon, Temazepam, Tetrabenazine, Thalidomide, Thiopental, Thioridazine, Thiothixene, Thonzylamine, TiaGABine, TiZANidine, Tofisopam, Tolcapone, Topiramate, TraMADol, Triazolam, Trifluoperazine, Trimeprazine, Trimipramine, Triprolidine, Valerian, Vigabatrin, Zaleplon, Ziconotide, Ziprasidone, Zolpidem, Zonisamide, Zopiclone, Zuclopenthixol

Discussion Each of the drugs listed in this monograph is capable of depressing the function of the central nervous system (CNS). Such effects may include, but are not limited to, ataxia, confusion, drowsiness, respiratory depression, and weakness.1 Concomitant use of two or more of these drugs may increase the risks associated with CNS depression. Caution is warranted.

Footnotes

1. Worthley LI, “Clinical Toxicology: Part I. Diagnosis and Management of Common Drug Overdosage,” Crit Care Resusc, 2002, 4(3):192-215. [PubMed 0000]

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[The last one is the combination of Remeron (mirtazapine) with Klonopin or Neurontin, or Topamax]

Title Mirtazapine / CNS Depressants

Risk Rating C: Monitor therapy

Summary CNS Depressants may enhance the CNS depressant effect of Mirtazapine. Severity Moderate Reliability Rating Fair

Patient Management Monitor for enhanced cognitive and motor impairment when mirtazapine is used in combination with a CNS depressant. Advise patients to avoid any unprescribed, illicit, or recreational use of other CNS depressants.

CNS Depressants Interacting Members Acrivastine, Afloqualone, Alcohol (Ethyl), Alfentanil, ALPRAZolam, Amisulpride, Amitriptyline, Amobarbital, Amoxapine, ARIPiprazole, ARIPiprazole Lauroxil, Asenapine, Baclofen, Benperidol, Benzhydrocodone, Bilastine, Blonanserin, Brexpiprazole, Brimonidine (Ophthalmic), Brivaracetam, Bromazepam, Bromperidol, Brompheniramine, Buclizine, Buprenorphine, BusPIRone, Butabarbital, Butalbital, Butorphanol, CarBAMazepine, Carbinoxamine, Cariprazine, Carisoprodol, Cetirizine (Systemic), Chloral Betaine, Chloral Hydrate, ChlordiazePOXIDE, Chlormethiazole, Chlorpheniramine, ChlorproMAZINE, Chlorzoxazone, Cinnarizine, Clemastine, CloBAZam, ClomiPRAMINE, ClonazePAM, CloNIDine, Clorazepate, Clothiapine, CloZAPine, Codeine, Cyclizine, Cyclobenzaprine, Cyproheptadine, Dantrolene, Desflurane, Desipramine, Desloratadine, Deutetrabenazine, Dexbrompheniramine, Dexchlorpheniramine, DiazePAM, Difenoxin, Dihydrocodeine, DimenhyDRINATE, Dimethindene (Systemic), DiphenhydrAMINE (Systemic), DiphenhydrAMINE (Topical), Diphenoxylate, Dosulepin, Doxepin (Systemic), Doxepin (Topical), Doxylamine, Droperidol, Ebastine, Efavirenz, Emedastine (Systemic), Entacapone, Eperisone, Estazolam, Eszopiclone, Ethosuximide, Ethotoin, Ethyl Loflazepate, Etizolam, Ezogabine, Felbamate, FentaNYL, Fexofenadine, Flibanserin, Flunarizine, Flunitrazepam, Flupentixol, FluPHENAZine, Flurazepam, Fosphenytoin, Gabapentin, Gabapentin Enacarbil, Glutethimide, GuanFACINE, Haloperidol, Halothane, Heroin, HYDROcodone, HYDROmorphone, HydrOXYzine, Iloperidone, Imipramine, Isoflurane, Ketamine, Ketotifen (Systemic), LamoTRIgine, LevETIRAcetam, Levocetirizine, Levorphanol, Lofepramine, Loprazolam, Loratadine, LORazepam, Lormetazepam, Loxapine, Lurasidone, Maprotiline, Meclizine, Melitracen [INT], Meperidine, Meprobamate, Meptazinol, Mequitazine, Metaxalone, Methadone, Methocarbamol, Methohexital, Methotrimeprazine, Methoxyflurane, Methsuximide, Mianserin, Midazolam, Mirtazapine, Molindone, Morphine (Liposomal), Morphine (Systemic), Moxonidine, Nalbuphine, Nalfurafine, Nefopam, Nitrazepam, Nitrous Oxide, Nordazepam, Nortriptyline, OLANZapine, Olopatadine (Systemic), Opium, Opium Tincture, Orphenadrine, Oxatomide, Oxazepam, Oxomemazine, OxyCODONE, OxyMORphone, Paliperidone, Paraldehyde, Paregoric, Pentazocine, PENTobarbital, Perampanel, Periciazine, Perphenazine, Pheniramine, PHENobarbital, Phenyltoloxamine, Phenytoin, Pholcodine, Pimozide, Pipamperone [INT], Pipotiazine, Pizotifen, Pomalidomide, Prazepam, Pregabalin, Primidone, Prochlorperazine, Promazine, Promethazine, Propofol, Protriptyline, Pyrilamine (Systemic), Quazepam, QUEtiapine, Ramelteon, Remifentanil, Reserpine, Rilmenidine, RisperiDONE, Rupatadine, Scopolamine (Ophthalmic), Scopolamine (Systemic), Secobarbital, Sevoflurane, Sodium Oxybate, Stiripentol, SUFentanil, Sulpiride, Suvorexant, Tapentadol, Tasimelteon, Temazepam, Tetrabenazine, Thalidomide, Thiopental, Thioridazine, Thiothixene, Thonzylamine, TiaGABine, TiZANidine, Tofisopam, Tolcapone, Topiramate, TraMADol, Triazolam, Trifluoperazine, Trimeprazine, Trimipramine, Triprolidine, Valerian, Vigabatrin, Zaleplon, Ziconotide, Ziprasidone, Zolpidem, Zonisamide, Zopiclone, Zuclopenthixol

Discussion In a study of 12 healthy volunteers, the concomitant administration of diazepam (15 mg) minimally influenced mirtazapine (15 mg) plasma concentrations but enhanced cognitive and motor impairment in an additive manner.1 Mirtazapine prescribing information recommends that patients be advised to avoid diazepam and related drugs during mirtazapine treatment.1

Footnotes

1. Prescribing information. Remeron (mirtazapine). Whitehouse Station, NJ: Merck & Co., Inc., 12/2011.

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