Millet VM, Dreisbach M, Bryson YJ. Double-blind controlled study of central nervous system side effects of amantadine, rimantadine, and chlorpheniramine. Antimicrob Agents Chemother. Amisulpride: Anti-Parkinson Agents Dopamine Agonist may diminish the therapeutic effect of Amisulpride. Amisulpride may diminish the therapeutic effect of Anti-Parkinson Agents Dopamine Agonist. Amantadine hydrochloride is a stable white or nearly white crystalline powder, freely soluble in water and soluble in alcohol and in chloroform. You may have increased sexual urges, unusual urges to gamble, or other intense urges while taking this medication. Talk with your doctor if you believe you have any intense or unusual urges while taking amantadine.
Anon. The national formulary. 14th ed. American Pharmaceutical Association. Care should be exercised when administering SYMMETREL amantadine hydrochloride to patients with liver disease. When amantadine and levodopa are started concurrently, rapid therapeutic benefits may occur. Amantadine dose should remain constant at 100 mg orally once or twice a day while the daily dose of levodopa is gradually increased to optimal benefit. Kornhuber, J; Bormann, J; Hübers, M; Rusche, K; Riederer, P 1991. "Effects of the 1-amino-adamantanes at the MK-801-binding site of the NMDA-receptor-gated ion channel: a human postmortem brain study". Eur. J. Pharmacol. Mol. Pharmacol. Sect.
The nerves that control your eyes connect directly to your brain, where images are processed. Many causes of double vision start in the brain. Klimov, Alexander I. 2007. "Surveillance of Resistance to Adamantanes among Influenza AH3N2 and AH1N1 Viruses Isolated Worldwide". Journal of Infectious Diseases. When SYMMETREL amantadine hydrochloride or anticholinergic antiparkinson drugs are each used with marginal benefit, concomitant use may produce additional benefit.
Sartori M, Pratt CM, Young JB. Torsade de pointe: malignant cardiac arrhythmia induced by amantadine poisoning. Am J Med. Anorectal manometry. A pressure monitor is inserted into the anus and rectum. This allows measurement of the strength of the sphincter muscles. May cause mydriasis; do not use in patients with untreated angle-closure glaucoma. You may have increased sexual urges, unusual urges to gamble, or other intense urges while taking this medicine. Talk with your doctor if this occurs.
For acute overdosing, general supportive measures should be employed along with immediate gastric lavage or induction of emesis. Fluids should be forced, and if necessary, given intravenously. The pH of the urine has been reported to influence the excretion rate of amantadine hydrochloride. Since the excretion rate of amantadine hydrochloride increases rapidly when the urine is acidic, the administration of urine acidifying drugs may increase the elimination of the drug from the body. The blood pressure, pulse, respiration and temperature should be monitored. The patient should be observed for hyperactivity and convulsions; if required, sedation, and anticonvulsant therapy should be administered. The usual dose of amantadine hydrochloride tablets is 100 mg twice a day. Occasionally, patients whose responses are not optimal with amantadine hydrochloride tablets at 200 mg daily may benefit from an increase up to 300 mg daily in divided doses. Plasma concentrations increased in patients with renal impairment. H3N2 strains circulating in the US were resistant to amantadine and rimantadine. 121 Resistance to amantadine and rimantadine among seasonal influenza A H3N2 circulating during recent influenza seasons has remained high. The initial dose of amantadine hydrochloride is 100 mg daily for patients with serious associated medical illnesses or who are receiving high doses of other antiparkinson drugs. After one to several weeks at 100 mg once daily, the dose may be increased to 100 mg twice daily, if necessary. Half-life prolonged in healthy geriatric adults. What is amantadine Symmetrel? Because of the possibility of serious adverse effects, caution should be observed when prescribing SYMMETREL amantadine hydrochloride to patients being treated with drugs having CNS effects, or for whom the potential risks outweigh the benefit of treatment. Elderly: Use with caution in the elderly; may be more susceptible to CNS effects using 2 divided daily doses may minimize this effect. These patients may require dosage reductions. Failed fertility has been reported during human in vitro fertilization IVF when the sperm donor ingested amantadine 2 weeks prior to, and during the IVF cycle. Data from earlier animal studies suggest that Symmetrel may have direct and indirect effects on dopamine neurons. There is no specific antidote for an overdose of amantadine. Use with caution and adjust dosage as needed in patients with CHF, peripheral edema, or orthostatic hypotension.
The safety and efficacy of amantadine hydrochloride in newborn infants and infants below the age of 1 year have not been established. What other drugs will affect amantadine? Degelau J, Somani S, Cooper SL, Irvine PW "Occurrence of adverse effects and high amantadine concentrations with influenza prophylaxis in the nursing home. It appears to primarily prevent the release of infectious viral nucleic acid into the host cell by interfering with the transmembrane domain of the viral M2 protein. Amantadine is also known to prevent viral assembly during replication. Amantadine inhibits the replication of influenza A virus isolates from each of the subtypes ie, H1N1, H2N2 and H3N2 but has very little or no activity against influenza B virus isolates. Fiore AE, Fry A, Shay D et al. Antiviral agents for the treatment and chemoprophylaxis of influenza --- recommendations of the Advisory Committee on Immunization Practices ACIP. MMWR Recomm Rep. Some of the side effects that can occur with amantadine may not need medical attention. As your body adjusts to the medicine during treatment these side effects may go away. Your health care professional may also be able to tell you about ways to reduce or prevent some of these side effects. Importance of not getting up suddenly from a sitting or lying position; notify clinician if dizziness or lightheadedness occurs. Do not receive a "live" nasal flu vaccine FluMist while taking amantadine, and for at least 48 hours after your last dose. You should not take amantadine if you have received a nasal flu vaccine within the past 14 days. For acute overdosing, general supportive measures should be employed along with immediate gastric lavage or induction of emesis. Fluids should be forced, and if necessary, given intravenously. The pH of the urine has been reported to influence the excretion rate of amantadine. Since the excretion rate of amantadine increases rapidly when the urine is acidic, the administration of urine acidifying drugs may increase the elimination of the drug from the body. The blood pressure, pulse, respiration and temperature should be monitored. The patient should be observed for hyperactivity and convulsions; if required, sedation, and anticonvulsant therapy should be administered. The patient should be observed for the possible development of arrhythmias and hypotension; if required, appropriate antiarrhythmic and antihypotensive therapy should be given. Electrocardiographic monitoring may be required after ingestion, since malignant tachyarrhythmias can appear after overdose. Because amantadine hydrochloride tablets have anticholinergic effects and may cause mydriasis, it should not be given to patients with untreated angle closure glaucoma. Most people do not need antiviral medicines. Influenza A prophylaxis: Refer to "Influenza A treatment" dosing. Note: Continue prophylaxis throughout the peak influenza activity in the community or throughout the entire influenza season in patients who cannot be vaccinated. Double vision can happen with no other symptoms. norfloxacin
Do not receive a "live" nasal flu vaccine FluMist while using amantadine, and for at least 48 hours after you stop taking amantadine. The vaccine may not work as well during this time, and may not fully protect you from disease. The most common cause of bowel is damage to the muscles around the anal sphincters. Vaginal can damage the anal sphincters or their nerves. That's why women are affected by accidental bowel leakage about twice as often as men. What is the incubation period for the flu? What Is Amantadine and How Does It Work? Side Effects List Keppra side effects by likelihood and severity. Influenza A prophylaxis: Chemoprophylaxis against signs and symptoms of influenza A virus infection; also refer to current Advisory Committee on Immunization Practices ACIP guidelines for recommendations during current influenza season. May diminish the therapeutic effect of Anti-Parkinson Agents Dopamine Agonist. Management: Consider using an alternative antipsychotic agent when possible in patients with Parkinson disease. If an atypical antipsychotic is necessary, consider using clozapine or quetiapine, which may convey the lowest interaction risk. Many effective treatments can help people with bowel incontinence. order meclizine online payment uk meclizine
Radiofrequency anal sphincter remodeling. A probe inserted into the anus directs controlled amounts of heat energy into the anal wall. Radiofrequency remodeling creates a mild injury to the sphincter muscles, which become thicker as they heal. Amantadine is an antiviral medication. It blocks the actions of viruses in your body. Pearlman JT, Kadish AH, Ramseyer JC "Vision loss associated with amantadine hydrochloride use. Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. SYMMETREL amantadine hydrochloride is well absorbed orally. Anon. Amantadine and rimantadine. In: Kucers A, Crowe SM, Grayson ML et al, eds. The use of antibiotics: a clinical review of antibacterial, antifungal and antiviral drugs. The usual dose of SYMMETREL amantadine hydrochloride is 100 mg twice a day. Occasionally, patients whose responses are not optimal with SYMMETREL amantadine hydrochloride at 200 mg daily may benefit from an increase up to 300 mg daily in divided doses. These urges stopped in some cases when dosage was reduced or the drug discontinued. Read the Guide and Instructions for Use provided by your before you start using beta-1A and each time you get a refill. If you have any questions, ask your doctor or pharmacist. Suicide attempts, some of which have been fatal, have been reported in patients treated with amantadine hydrochloride, many of whom received short courses for influenza treatment or prophylaxis. The incidence of suicide attempts is not known and the pathophysiologic mechanism is not understood. Suicide attempts and suicidal ideation have been reported in patients with and without prior history of psychiatric illness. Amantadine hydrochloride can exacerbate mental problems in patients with a history of psychiatric disorders or substance abuse. Patients who attempt suicide may exhibit abnormal mental states which include disorientation, confusion, depression, personality changes, agitation, aggressive behavior, hallucinations, paranoia, other psychotic reactions, and somnolence or insomnia. Because of the possibility of serious adverse effects, caution should be observed when prescribing amantadine hydrochloride tablets to patients being treated with drugs having CNS effects, or for whom the potential risks outweigh the benefit of treatment. When used for parkinsonian syndrome, onset of action usually within 48 hours. Davies WL et al. Antiviral activity of amantadine. Science. Hong Kong infection. Lancet.
Amantadine hydrochloride oral solution USP contains 50 mg of amantadine hydrochloride per 5 mL and has the following inactive ingredients: citric acid anhydrous methylparaben, propylene glycol, propylparaben, purified water, sorbitol solution, and natural and artificial flavoring. CPK, BUN, serum creatinine, alkaline phosphatase, LDH, bilirubin, GGT, SGOT, and SGPT. Hallucinations, confusion, ataxia, headache, somnolence, agitation, and fatigue have been reported in 1% to 5% of patients. Some patients who do not respond to anticholinergic antiparkinson drugs may respond to amantadine hydrochloride. When amantadine hydrochloride or anticholinergic antiparkinson drugs are each used with marginal benefit, concomitant use may produce additional benefit. Overdose symptoms may include fever, anxiety, severe headache, confusion, hallucinations, agitation, aggression, personality changes, tremor, problems with balance or walking, fast or uneven heart rate, urinating less than usual or not at all, trouble breathing, seizure convulsion or fainting. Amantadine can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. Centers for Disease Control and Prevention. Influenza antiviral medications: summary for clinicians. From CDC website. Moderate Risk QTc-Prolonging Agents: QTc-Prolonging Agents Indeterminate Risk and Risk Modifying may enhance the QTc-prolonging effect of Moderate Risk QTc-Prolonging Agents. Practice GLP and according to current recommended methodology. Influenza viruses change over time. Emergence of resistance mutations could decrease drug effectiveness. Other factors for example, changes in viral virulence might also diminish clinical benefit of antiviral drugs. Prescribers should consider available information on influenza drug susceptibility patterns and treatment effects when deciding whether to use amantadine hydrochloride tablets. Although antivirals used for treatment or prevention of influenza, including amantadine, may be used concomitantly with or at any time before or after influenza virus vaccine inactivated, 100 these antivirals may inhibit the vaccine virus contained in influenza vaccine live intranasal. 1 2 6 100 See Influenza Virus Vaccines under Interactions. If you take this medicine for Parkinson symptoms, your doctor may occasionally change your dose to make sure you get the best results. When amantadine hydrochloride and levodopa are initiated concurrently, the patient can exhibit rapid therapeutic benefits. Amantadine hydrochloride should be held constant at 100 mg daily or twice daily while the daily dose of levodopa is gradually increased to optimal benefit. zoloft order online store europe zoloft
Patients with a history of epilepsy or other “seizures” should be observed closely for possible increased seizure activity. Have you hit your head, fallen, or been unconscious? Drink several glasses of water each day. Alves Galvão, MG; Rocha Crispino Santos, MA; Alves da Cunha, AJ 21 November 2014. "Amantadine and rimantadine for influenza A in children and the elderly. Because amantadine hydrochloride is primarily excreted in the urine, it accumulates in the plasma and in the body when renal function declines. Thus, the dose of amantadine hydrochloride should be reduced in patients with renal impairment and in individuals who are 65 years of age or older. cheap ibuprofen generic
The absence of a warning for a given drug or combination thereof in no way should be construed to indicate safety, effectiveness, or appropriateness for any given patient. Drugs. Patients initially deriving benefit from Amantadine Hydrochloride Tablets not uncommonly experience a fall-off of effectiveness after a few months. Benefit may be regained by increasing the dose to 300 mg daily. Alternatively, temporary discontinuation of Amantadine Hydrochloride Tablets for several weeks, followed by reinitiation of the drug, may result in regaining benefit in some patients. A decision to use other antiparkinson drugs may be necessary. For the reasons stated above, patients and providers are advised to monitor for melanomas frequently and on a regular basis when using amantadine hydrochloride tablets for any indication. When should a person go to the emergency department for the flu? The total daily dose is 200 mg given as two teaspoonfuls of oral solution twice a day. The 100 mg daily dose has not been studied in this pediatric population. Therefore, there are no data which demonstrate that this dose is as effective as or is safer than the 200 mg daily dose in this patient population. The apparent oral plasma clearance of amantadine is reduced and the plasma half-life and plasma concentrations are increased in healthy elderly individuals age 60 and older. RxList is part of the WebMD Health Network. The opinions expressed in the WebMD User Reviews are solely those of the User, who may or may not have medical or scientific training, and do not represent the opinions of WebMD. These member reviews have not been reviewed by a WebMD physician or any member of the WebMD editorial staff for accuracy, balance, objectivity, or any other purpose except for compliance with our Terms and Conditions. Amantadine is used to prevent or treat a certain type of flu A. If you have been infected with the flu, this medication may help make your symptoms less severe and shorten the time it will take you to get better. Taking amantadine if you have been or will be exposed to the flu may help to prevent you from getting the flu. This medication is an that is believed to work by stopping growth of the flu virus. This medication is not a vaccine. To increase the chance that you will not get the flu, it is important to get a once a year at the beginning of every flu season, if possible. Do you tend to tilt your head to one side?
Nausea, 1 2 6 dizziness lightheadedness 1 2 6 49 insomnia. Use with caution in patients with recurrent eczematoid dermatitis. Because amantadine hydrochloride is mainly excreted in the urine, it accumulates in the plasma and in the body when renal function declines. What can people eat when they have the flu? Overdose symptoms may include fever, aggression, behavior changes, hallucinations, severe headache or pounding in your ears, muscle stiffness, problems with balance or walking, fast heart rate, urinating less than usual, trouble breathing, seizure convulsion or fainting. What should I avoid while taking amantadine? Montanari C et al. Urinary excretion of amantadine by the elderly. Eur J Clin Pharmacol. Amantadine Hydrochloride Capsules, USP is not a substitute for early vaccination on an annual basis as recommended by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices. Influenza A variants with reduced in vitro sensitivity to amantadine have been isolated from epidemic strains in areas where adamantane derivatives are being used. Influenza viruses with reduced in vitro sensitivity have been shown to be transmissible and to cause typical influenza illness. The quantitative relationship between the in vitro sensitivity of influenza A variants to amantadine and the clinical response to therapy has not been established. The recommended dosage for patients on is 200 mg every 7 days. Horadam VW, Sharp JG, Smilack JD et al. Pharmacokinetics of amantadine hydrochloride in subjects with normal and impaired renal function. Ann Intern Med. If you are using this medication at home, learn all preparation and usage instructions from your professional. Before using, check this product visually for particles or discoloration. If either is present, not use the liquid. Learn how to store and discard medical supplies safely. The concurrent use of amantadine with live attenuated influenza vaccine LAIV intranasal has not been evaluated. However, because of the potential for interference between these products, LAIV should not be administered within 2 weeks before or 48 hours after administration of amantadine, unless medically indicated. The concern about possible interference arises from the potential for antiviral drugs to inhibit replication of live vaccine virus. Trivalent inactivated influenza vaccine can be administered at any time relative to use of amantadine. buy cheapest ditropan store uk
Amantadine should be used during pregnancy only if the potential benefit justifies the potential risk to the embryo or fetus. Blanpied, TA; Clarke, RJ; Johnson, JW 2005. "Amantadine inhibits NMDA receptors by accelerating channel closure during channel block". Journal of Neuroscience. Influenza viruses change over time. Emergence of resistance mutations could decrease drug effectiveness. Other factors for example, changes in viral virulence might also diminish clinical benefit of antiviral drugs. Prescribers should consider available information on influenza drug susceptibility patterns and treatment effects when deciding whether to use Amantadine Hydrochloride Capsules, USP. Psychiatric side effects have included depression, anxiety, irritability, nervousness, and dream abnormality in 1% to 5% of patients. If you are currently using the medication listed above, tell your doctor or pharmacist before starting trihexyphenidyl. The initial dose of amantadine hydrochloride tablets is 100 mg daily for patients with serious associated medical illnesses or who are receiving high doses of other antiparkinson drugs. After one to several weeks at 100 mg once daily, the dose may be increased to 100 mg twice daily, if necessary. Occasionally, patients whose responses are not optimal with amantadine hydrochloride tablets at 200 mg daily may benefit from an increase up to 400 mg daily in divided doses. However, such patients should be supervised closely by their physicians. Patients initially deriving benefit from Symmetrel not uncommonly experience a fall-off of effectiveness after a few months. Benefit may be regained by increasing the dose to 300 mg daily. Alternatively, temporary discontinuation of Symmetrel for several weeks, followed by reinitiation of the drug, may result in regaining benefit in some patients. A decision to use other antiparkinson drugs may be necessary. The effect of amantadine on embryofetal and peri-postnatal development has not been adequately tested, that is, in studies conducted under Good Laboratory Practice GLP and according to current recommended methodology. Fatalities reported following overdosage. 1 2 6 Overdosage has resulted in cardiac arrhythmia, tachycardia, hypertension respiratory, renal, or CNS toxicity; may be related to anticholinergic effects of the drug. Deaths due to drug accumulation overdosage reported in patients with renal impairment who received amantadine dosage higher than recommended for their degree of renal impairment. 1 2 6 See Renal Impairment under Cautions. opad.info ciprofloxacin
Note: Patients with a serious concomitant illness or those receiving high doses of other antiparkinson drugs should be started at 100 mg once daily; may increase to 100 mg twice daily, if needed, after one to several weeks. Has antiviral activity against some strains of influenza A, including susceptible H1N1, H2N2, and H3N2. Follow all directions on your prescription label. Do not take this medicine in larger or smaller amounts or for longer than recommended. Overdose symptoms may include fever, aggression, behavior changes, hallucinations, severe headache or pounding in your ears, muscle stiffness, problems with balance or walking, fast heart rate, urinating less than usual, trouble breathing, seizure convulsion or fainting. What should I avoid while taking Symmetrel amantadine? Prophylactic dosing should be started in anticipation of an influenza A outbreak and before or after contact with individuals with influenza A virus respiratory tract illness.
Care should be exercised when administering amantadine hydrochloride to patients with liver disease. Rare instances of reversible elevation of liver enzymes have been reported in patients receiving amantadine hydrochloride, though a specific relationship between the drug and such changes has not been established. Exercises. Begin a program of regularly contracting the muscles used to control urinary flow . This builds strength in the pelvic muscles and may help reduce bowel incontinence. Amantadine's efficacy can wane after a few months. If patient is not at maximum tolerated dose, increasing dose may help. Alternatively, temporary discontinuation of drug for several weeks may help to recover some of the drug's effects when it is reinstated. The use of other antiparkinson drugs may be necessary. Care should be exercised when administering adrenergic agents, such as isoproterenol, to patients with a Symmetrel overdose, since the dopaminergic activity of Symmetrel has been reported to induce malignant arrhythmias. The dosage is based on your medical condition and response to treatment. To reduce your risk of side effects, your doctor may direct you to start this medication at a low dose and gradually increase your dose. Follow your doctor's instructions carefully. Use this medication regularly to get the most benefit from it. To help you remember, use it on the same day each week. CHF reported; monitor patients with a history of CHF or peripheral edema. 1 2 6 Dosage adjustment may be needed. Hong Kong. Antimicrob Agents Chemother. Agents with anticholinergic properties may potentiate the anticholinergic-like side effects of amantadine. Patients with a history of epilepsy or other seizure disorders should be observed closely for possible increased seizure activity. Occasionally, patients whose responses are not optimal with Symmetrel at 200 mg daily may benefit from an increase up to 400 mg daily in divided doses. However, such patients should be supervised closely by their physicians. Consult WARNINGS section for dosing related precautions. Avoid taking diet pills, caffeine pills, or other stimulants such as ADHD medications without your doctor's advice. Taking a stimulant together with amantadine can increase your risk of unpleasant side effects. clarithromycin
At least one case of dropped head syndrome associated with unbalanced contraction of the neck muscles has been reported. Neuroleptic malignant syndrome, involuntary muscle contractions, coma, stupor, hypokinesia, hypertonia, gait abnormalities, paresthesia, EEG changes, and tremor have been reported during postmarketing experience. Agitation, hallucinations, stupor, and slurred speech have also occurred after abrupt discontinuation. Importance of seeking immediate medical attention for suspected overdose. Committee on Infectious Disease. What should I avoid while taking amantadine Symmetrel? Influenza viruses change over time. Surgery almost always fixes them. Sporadic cases of possible Neuroleptic Malignant Syndrome NMS have been reported in association with dose reduction or withdrawal of amantadine hydrochloride therapy. Therefore, patients should be observed carefully when the dosage of amantadine hydrochloride is reduced abruptly or discontinued, especially if the patient is receiving neuroleptics. Coadministration of quinine or quinidine with amantadine was shown to reduce the renal clearance of amantadine by about 30%. Antiviral drugs for prophylaxis and treatment of influenza. Amantadine is no longer recommended for treatment of influenza A infection. carafate
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Patients with a history of congestive heart failure or peripheral edema should be followed closely as there are patients who developed congestive heart failure while receiving amantadine hydrochloride. Symmetrel should be continued daily for at least 10 days following a known exposure. If Symmetrel is used chemoprophylactically in conjunction with inactivated influenza A virus vaccine until protective antibody responses develop, then it should be administered for 2 to 4 weeks after the vaccine has been given. When inactivated influenza A virus vaccine is unavailable or contraindicated, Symmetrel should be administered for the duration of known influenza A in the community because of repeated and unknown exposure. order fenofibrate tablets 100mg
Patients initially deriving benefit from amantadine hydrochloride tablets not uncommonly experience a fall-off of effectiveness after a few months. Benefit may be regained by increasing the dose to 300 mg daily. Alternatively, temporary discontinuation of amantadine hydrochloride tablets for several weeks, followed by reinitiation of the drug, may result in regaining benefit in some patients. A decision to use other antiparkinson drugs may be necessary. Amantadine hydrochloride tablets prescribing information. Minneapolis, MN; 2012 Apr. Leukocytosis and agranulocytosis have been reported during postmarketing experience.
Or are they slightly slanted? Have you had any other symptoms besides double vision? It sits behind your pupil and helps focus light onto your retina. Inject this medication into a muscle as directed by your doctor, usually once a week. It is best to use this medication near to reduce side effects. The dose of anticholinergic drugs or of amantadine hydrochloride should be reduced if atropine-like effects appear when these drugs are used concurrently. Abrupt discontinuation may also precipitate delirium, agitation, delusions, hallucinations, paranoid reaction, stupor, anxiety, depression and slurred speech. order gynera online legal
Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Take this medication by mouth, usually 3 to 4 times a day with meals and at bedtime, or as directed by your doctor. Your doctor may start you at a low dose and increase your dose slowly to find the best dose for you. The dosage is based on your medical condition, age, and response to therapy. Highest Risk QTc-Prolonging Agents: QTc-Prolonging Agents Indeterminate Risk and Risk Modifying may enhance the QTc-prolonging effect of Highest Risk QTc-Prolonging Agents. Management: Avoid such combinations when possible. Use should be accompanied by close monitoring for evidence of QT prolongation or other alterations of cardiac rhythm.