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Delirium probably induced by clarithromycin in a patient receiving fluoxetine
P T Pollak1, I S Sketris, S L MacKenzie
1Department of Medicine, Dalhousie University, Victoria General Hospital, Halifax, Nova Scotia, Canada.
Background:
Clarithromycin is a macrolide antibiotic very similar to erythromycin in structure and spectrum of activity. It has gained increasing use since its release in Canada in May 1992, partly because it is promoted as having less potential for drug interactions and adverse effects. However, as with all new medications, a high degree of vigilance for unreported adverse effects is advisable.
Case Summary:
A healthy 53-year-old lawyer was receiving long-term fluoxetine 80 mg hs and nitrazepam 10 mg hs for depression and mild sleep apnea. Subsequent to initiation of treatment with clarithromycin for a respiratory infection, he rapidly developed delirium, which cleared quickly after stopping all 3 medications. The delirium and psychosis did not recur when the infection was treated with erythromycin alone or after restarting fluoxetine and nitrazepam therapy at previous dosages in the absence of antibiotics.
Discussion:
This man's delirium is consistent with fluoxetine intoxication, which appears to have resulted from inhibition of hepatic cytochrome P450 metabolism by clarithromycin. Undiagnosed, this serious drug reaction could have lead to serious medical and social consequences.
Conclusions:
As the use of clarithromycin increases, the potential for interactions with other drugs metabolized by the P450 enzyme system may be realized. Clinicians should consider which other medications a patient is receiving before prescribing clarithromycin or any macrolide antibiotic with potential to influence the P450 system.
Insights
Clarithromycin, a macrolide antibiotic, can cause fluoxetine toxicity by inhibiting drug metabolism. This case highlights the risk of serious drug interactions with clarithromycin, emphasizing careful patient monitoring.
Area of Science:
- Pharmacology
- Drug Metabolism
- Clinical Toxicology
Background:
- Clarithromycin is a widely used macrolide antibiotic.
- It is often perceived to have fewer drug interactions than erythromycin.
- Vigilance for adverse effects of new medications is crucial.
Observation:
- A patient on long-term fluoxetine and nitrazepam developed delirium after starting clarithromycin.
- Symptoms resolved upon discontinuation of all three medications.
- Delirium and psychosis did not recur with erythromycin or after restarting fluoxetine and nitrazepam without clarithromycin.
Findings:
- The patient's delirium was consistent with fluoxetine intoxication.
- Clarithromycin likely inhibited the hepatic cytochrome P450 system, impairing fluoxetine metabolism.
- This interaction represents a serious, potentially undiagnosed drug reaction.
Implications:
- Increased use of clarithromycin may lead to more recognized interactions with P450-metabolized drugs.
- Clinicians must consider a patient's medication regimen before prescribing clarithromycin.
- Awareness of potential P450 inhibition by macrolides is essential for patient safety.