Carbamazepine (Tegretol) - Drug information

Carbamazepine reduces the neuronal discharges by inhibiting the influx of sodium ions in the cell membranes. It is indicated for the treatment of the following disorders:

  • Bipolar 1 disorder
  • Epilepsy
    • Treatment of partial seizures with complex symptomatology.
    • Generalized tonic-clonic or grand mal seizures
    • Mixed seizure patterns
    • It is not indicated for the treatment of absence seizures
  • Pain associated with Trigeminal or glossopharyngeal neuralgia.
  • Neuropathic pains in combination with an opioid in critically ill patients
  • Neuropsychiatric symptoms of dementia
  • Restless legs syndrome

Carbamazepine dose in Adults

Carbamazepine dose in Epilepsy:

Note: The total daily intravenous dose should be equivalent to 70% of the previous total daily oral dose administered in four divided doses and infused over 30 minutes.

  • Oral carbamazepine 400 mg/day in two or four divided doses. Titrate the dose by increments of 200 mg/day at weekly intervals until optimal response and therapeutic levels are achieved (usual dose is 800 to 1,200 mg/day)
  • The maximum recommended dose is 1,600 mg/day.

Trigeminal or glossopharyngeal neuralgia:

  • 200 mg/day of the extended-release formulation in a single dose or in two divided doses (immediate-release tablets) or four divided doses (oral suspension).
  • Titrate the dose by increments of 200 mg/day at weekly intervals to the usual daily maintenance dose of 400 to 800 mg or to the maximum dose of 1200 mg/day.

Use in Bipolar disorder

  • 400 mg/day in two divided doses to a maximum dose of 1,600 mg/day.

Neuropathic pain in critically ill patients: 100 mg thrice daily administered orally in combination with opioids.

Neuropsychiatric symptoms of dementia:

  • 100 mg once or twice daily to a maximum of 400 to 600 mg daily in 2 to 4 divided doses.

Restless legs syndrome:

  • 100 to 600 mg daily.

Carbamazepine Dose in Children

Note: Patients of Asian ancestry should be tested for HLA-B*1502 allele prior to initiating carbamazepine therapy.

Dose in Seizure disorder:

  • Infants and Children less than 6 years of age:
    • 10 to 20 mg/kg/day of the immediate release tablets formulation in two or 3 divided doses. The dose should be titrated at weekly intervals until optimal response or the maximum daily dose of 35 mg/kg/day.
    • The same dose of the suspension should be divided into three or four divided doses to avoid fluctuations in trough and peak levels.
  • Children older than 6 to 12 years of age:
    • 100 mg twice daily (immediate-release & extended-release tablets). Titrate the dose by100 mg/day at weekly intervals to the usual maintenance dose range of 400 to 800 mg/day thrice or four times a day or to the maximum daily dose of 1,000 mg/day.
    • The oral suspension should be divided into four doses to avoid fluctuations in the peak and trough levels.
  • Adolescents:
    • 200 mg twice daily (immediate-release & extended-release tablets). Titrate the dose at weekly increments by up to 200 mg/day to the usual maintenance daily dose range of 800 to 1,200 mg/day in three or four divided doses.
    • The oral suspension should be administered in three or four divided doses to avoid fluctuations in the peak and trough levels of the drug.

The recommended maximum daily doses are as follows:

  • Adolescents 15 years of age or less: 1,000 mg/day
  • Adolescents older than 15 years of age: 1,200 mg/day

Pregnancy Risk factor D

  • Carbamazepine use in pregnancy has been shown to be teratogenic. 
  • It has been linked to spina bifida and craniofacial malformations, hypospadias, and cardiovascular malformations.
  • It is best to avoid using it during the first trimester of pregnancy if you are trying to treat a bipolar disorder. 
  • Alternative methods of contraception are recommended as it can lower the plasma levels of hormonal contraceptives.

Use of Carbamazepine while breastfeeding

  • Carbamazepine as well as its active epoxide metabolism metabolite may be excreted in breastmilk and can cause hepatic dysfunction in neonates.
  • Manufacturers recommend weighing the benefits and risks. 
  • If adverse events are observed in the neonate, breastfeeding should not be done.

Carbamazepine Dose in Renal Disease:

 Intracavenous carbamazepine dose adjustment for renal disease

  • Patients with a CrCl greater than 60 mL/minute do not need to adjust their dose
  • Patients with CrCl 15 to 60 mL/minute should be avoided

Dosage adjustment for oral carbamazepine:

  • The manufacturer has not offered any dose adjustment for patients with kidney disease. 
  • 75% should be advised to patients who have an eGFR below 10 ml/min and patients on hemodialysis or peritoneal dialysis.
  • Patients on CRRT (continuous kidney replacement therapy) do not need to adjust their dose.

Carbamazepine Dose in Liver Disease:

  • Carbamazepine should be used with caution in patients with the liver disease since it is metabolized primarily in the liver.
  • However, the manufacturer has not recommended any dose adjustment in patients with liver disease.

Side Effects of Carbamazepine

  • Central nervous system:
    • Dizziness, drowsiness, and ataxia.
  • Gastrointestinal:
    • Nausea and vomiting

Less Common side effects:

  • Cardiovascular:
    • Hypertension
  • Central nervous system:
    • Speech disturbance, abnormal thoughts,  paresthesia, twitching, and vertigo
  • Dermatologic:
    • Pruritus and skin rash
  • Gastrointestinal:
    • Constipation and xerostomia
  • Neuromuscular & skeletal:
    • Weakness and tremors
  • Ophthalmic:
    • Blurred vision

Rare side effects:

  • Arrhythmias
  • heart blocks
  • Blood pressure variability
  • agitation
  • depression
  • visual hallucinations
  • ataxia
  • dysarthria
  • erythema nodosum
  • exfoliative dermatitis
  • drug-induced lupus
  • neuroleptic malignant syndrome
  • fertility issues
  • hematological effects
  • cholestasis
  • anaphylactic reactions

Contraindications to carbamazepine include:

  • Allergy or sensitivity to carbamazepine, any component of the formulation, and tricyclic antidepressants
  • Depression of the bone marrow
  • Concomitant use or within 14 days after an MAO inhibitor treatment
  • Use of boceprevir or nefazodone concurrently
  • Use delavirdine or other N-NRTIs (non-nucleoside transcriptase inhibitors), in conjunction with CYP3A4.
  • Heart block
  • Grave liver disease
  • Patients with porphyria (AIP-acute intermittent porphyria; VP-variegate porphyria; and PCT-porphyriacutanea tarda).
  • Grave blood disorder
  • Itraconazole and voriconazole can be used simultaneously

Warnings and Precautions

  • Blood dyscrasias[US Boxed Warning]
    • You should monitor the patient for signs of bone marrow toxicities, such as anemia and agranulocytosis.
    • If there is significant bone marrow suppression, treatment should be stopped.
    • Patients should report any symptoms such as fever, sore throats, oral ulcers, infections or bleeding from any area.
  • Depression in the CNS:
    • Carmazepine-induced CNS depression can lead to mental and physical impairments. 
    • Before initiating therapy, patients who use heavy machinery should be notified.
  • Toxicity to the skin:[US Boxed Warning]
    • Therapy can cause severe and sometimes fatal reactions. These include Stevens-Johnson syndrome and toxic epidermal necrolysis.
    • Patients of Asian descent with the variant HLAB*1502 allele are at greater risk. Before starting therapy with carbamazepine, high-risk patients should be screened.
    • Patients with the allele should avoid carbamazepine. Combining carbamazepine with antiepileptic drugs may increase the risk of TEN or SJS.
  • Hepatotoxicity:
    • Carbamazepine-induced livertoxicity can range from mild elevations of liver enzymes to severe hepatic impairment. Rare cases of disappearing bile duct syndromes were reported.
  • Hyponatremia:
    • Patients receiving carbamazepine therapy may develop hyponatremia due to the SIADH. Patients with hyponatremia should stop taking carbamazepine therapy.
  • Suicidal thoughts:
    • Suicidal tendencies have been linked to the use of Carbamazepine.
  • Anticholinergic Sensitivity:
    • Patients who have high intraocular pressure or urinary retention should not take this drug.
  • Stop using antiepileptics
    • Avoid abrupt withdrawal of antiepileptics due to the potential for increasing seizure frequency.

Carbamazepine: Drug Interaction

Notice: Drug Interaction Categories

  • Risk Factor C: Use Combination Carefully
  • Risk Factor D: Take into consideration treatment modification
  • Risk Factor X: Avoid concurrent use

Risk Factor C (Monitor therapy).
Acetaminophen CarBAMazepine could increase Acetaminophen metabolism. This could 1) decrease the effects of Acetaminophen; 2) increase the risk for liver damage.
Albendazole CarBAMazepine can decrease serum levels of active metabolites of Albendazole.
Allopurinol Increases the serum concentration of CarBAMazepine.
Apalutamide CYP3A4 Inducers Strong may reduce serum Apalutamide concentrations.
Bazedoxifene CarBAMazepine can decrease serum levels of Bazedoxifene. This could result in decreased efficacy, or, if combined with estrogen therapy (egg replacement), an increase in the risk of endometrial hypoplasia.
Benperidol CYP3A4 Inducers Strong may reduce the serum level of Benperidol.
Benzhydrocodone CYP3A4 Inducers Strong may reduce the serum concentrations of Benzhydrocodone. Hydrocodone serum concentrations may be decreased.
Bosentan Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
Brentuximab Vedotin CYP3A4 Inducers Strong may reduce the serum Brentuximab Vedotin concentration. Concentrations of the active monomethyl auristatin E component (MMAE) may be decreased.
Brentuximab Vedotin Brentuximab Vedotin serum concentration may be decreased by P-glycoprotein/ABCB1 inducers. Concentrations of the active monomethyl auristatin E component (MMAE) may be decreased.
Brivaracetam Could increase serum levels of CarBAMazepine's active metabolite(s). CarBAMazepine can decrease serum Brivaracetam concentrations.
Bromperidol Bromperidol serum concentration may be decreased by CarBAMazepine
Buprenorphine CYP3A4 Inducers Strong may reduce the serum level of buprenorphine.
Calcifediol CYP3A4 Inducers Strong may reduce Calcifediol serum concentrations
Cannabidiol CYP3A4 Inducers, Strong may reduce the serum Cannabidiol concentration.
Cannabis CYP3A4 Inducers Strong may reduce the serum cannabis concentration. The serum concentrations of tetrahydrocannabinol or cannabidiol may decrease.
Carbonic Anhydrase inhibitors Increases serum CarBAMazepine concentration. Brinzolamide and Dorzolamide are exceptions.
Celiprolol The serum concentration of Celiprolol may be decreased by P-glycoprotein/ABCB1 inducers.
Chloramphenicol Ophthalmic May increase the toxic/adverse effects of Myelosuppressive Agents.
Chlormethiazole CarBAMazepine could lower the serum level of Chlormethiazole.
ChlorproPAMIDE CYP3A4 Inducers Strong may reduce the serum level of ChlorproPAMIDE.
Cimetidine Increased serum CarBAMazepine concentrations may occur. One week after starting cimetidine, the serum carbamazepine level might return to normal.
Ciprofloxacin Systemic Increases the serum concentration of CarBAMazepine.
Citalopram CarBAMazepine could lower Citalopram's serum concentration.
Clindamycin (Systemic). CYP3A4 Inducers(Strong) can decrease serum Clindamycin Systemic concentration. For more information on this combination, refer to the clindamycin systemic - rifampin drug interactions monograph.
Clofazimine High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
ClomiPRAMINE CarBAMazepine could increase ClomiPRAMINE serum concentrations.
Codeine CYP3A4 Inducers Strong may reduce serum levels of active metabolite(s), Codeine.
Systemic Corticosteroids CYP3A4 Inducers, Strong, may reduce the serum level of Corticosteroids Systemic. Exceptions: Hydroxycortisone Systemic; PrednisoLONE® (Systemic); and PredniSONE.
CYP2B6 Substrates High Risk with Inducers Moderate CYP2B6 Inducers may reduce serum concentrations of CYP2B6 Substrates (High Risk with Inducers).
Moderate CYP3A4 Inducers Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
Strong CYP3A4 Inducers Could lower the serum level of CarBAMazepine.
Moderate CYP3A4 inhibitors Might decrease metabolism of CYP3A4 substrates (High Risk with Inhibitors).
Danazol May reduce the metabolism of CarBAMazepine.
Darunavir Increases the serum concentration of CarBAMazepine.
Deferasirox Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
Desmopressin CarBAMazepine could increase the toxic/adverse effects of Desmopressin.
Diethylstilbestrol CYP3A4 Inducers Strong may reduce the serum concentrations of Diethylstilbestrol.
Doxercalciferol CYP3A4 Inducers Strong may increase serum levels of active metabolites of Doxercalciferol.
Dronabinol CYP3A4 Inducers Strong may reduce Dronabinol's serum concentration.
Elagolix CYP3A4 Inducers Strong may reduce the serum Elagolix concentration.
Eslicarbazepine CarBAMazepine could increase the toxic/adverse effects of Eslicarbazepine. CarBAMazepine could decrease serum Eslicarbazepine concentrations.
Estriol (Systemic). CYP3A4 Inducers Strong may reduce the serum Estriol (Systemic) concentration.
Estriol (Topical). CYP3A4 Inducers Strong may reduce the serum Estriol (Topical) concentration.
Etizolam CYP3A4 Inducers Strong may reduce the serum Etizolam concentration.
Evogliptin CYP3A4 Inducers Strong may reduce the serum level of Evogliptin.
FentaNYL FentaNYL serum concentration may be decreased by strong CYP3A4 inducers.
Fingolimod CarBAMazepine could decrease Fingolimod serum concentrations.
Fluconazole Increases the serum concentrations of CarBAMazepine.
Flunarizine Flunarizine serum concentrations may be decreased by CarBAMazepine
FLUoxetine Increases the serum concentration of CarBAMazepine.
FluvoxaMINE Increases the serum concentrations of CarBAMazepine.
Gestrinone CarBAMazepine could lower the serum Gestrinone concentration.
Grapefruit Juice Increases the serum concentration of CarBAMazepine.
Haloperidol CarBAMazepine could lower the serum concentrations of Haloperidol.
HYDROcodone CYP3A4 Inducers Strong may reduce serum HYDROcodone concentrations.
Hydrocortisone Systemic Hydrocortisone (Systemic) serum concentration may be decreased by CYP3A4 Inducers.
Ifosfamide CYP3A4 Strong may increase serum levels of Ifosfamide's active metabolite(s). CYP3A4 Inducers(Strong) could decrease serum concentrations the active metabolite (s) of Ifosfamide.
Isoniazid CarBAMazepine could increase the hepatotoxic effects of Isoniazid. CarBAMazepine may be increased by Isoniazid.
Lacosamide Antiepileptic agents (Sodium Channel Blockers), may increase the toxic/adverse effects of Lacosamide. The risk of bradycardia, ventricular arrhythmias or prolonged PR interval may increase.
LevETIRAcetam CarBAMazepine may have an adverse/toxic effect. CarBAMazepine can lower the serum concentrations of LevETIRAcetam.
Levomethadone CarBAMazepine can lower the serum level of Levomethadone.
Lithium CarBAMazepine could increase the toxic/adverse effects of Lithium.
Loxapine Increased serum levels of CarBAMazepine active metabolite(s).
Mebendazole CarBAMazepine could lower the serum concentrations of Mebendazole.
Methadone CarBAMazepine could lower Methadone's serum concentration.
Methylfolate Could lower the serum level of CarBAMazepine.
Mianserin CarBAMazepine may have a less therapeutic effect. CarBAMazepine can decrease Mianserin serum concentrations.
Neuromuscular-Blocking agents (Nondepolarizing). CarBAMazepine could decrease serum levels of Neuromuscular-Blocking Agents.
OLANZapine CarBAMazepine could lower OLANZapine serum concentrations.
Orlistat May lower the serum concentrations of Anticonvulsants.
Paliperidone CarBAMazepine could lower the serum level of Paliperidone.
P-glycoprotein/ABCB1 Substrates P-glycoprotein/ABCB1 inducers may reduce the serum concentration of Pglycoprotein/ABCB1 Substrates. Inducers of P-glycoprotein may limit the distribution and availability of pglycoprotein substrates in certain cells/tissues/organs that have high levels (e.g. brain, T-lymphocytes, testes etc.). .
Pimavanserin CYP3A4 Inducers Strong may reduce the serum concentrations of Pimavanserin.
Pravastatin Pravastatin serum concentration may be decreased by CarBAMazepine
PrednisoLONE Systemic CYP3A4 Inducers Strong may reduce the serum level of PrednisoLONE Systemic.
PredniSONE PredniSONE serum concentration may be decreased by strong CYP3A4 inducers.
Promazine May increase the myelosuppressive effects of Myelosuppressive Drugs.
Propacetamol CarBAMazepine could increase Propacetamol's metabolism. This could 1) reduce the desired effects of Propacetamol and 2) increase the chance of liver damage.
Propafenone CYP3A4 Inducers Strong may reduce the serum Propafenone concentration.
Ramelteon CYP3A4 Inducers Strong may reduce serum Ramelteon concentrations
Reboxetine CYP3A4 Inducers Strong may reduce the serum concentrations of Reboxetine.
Resveratrol Increases the serum concentration of CarBAMazepine.
Rosuvastatin Rosuvastatin serum concentration may be decreased by CarBAMazepine
Rufinamide Could decrease serum CarBAMazepine concentration. Rufinamide may be lessened by CarBAMazepine.
Ruxolitinib CYP3A4 Inducers Strong may reduce the serum Ruxolitinib concentration.
Sarilumab Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
SAXagliptin CYP3A4 Inducers Strong may reduce serum SAXagliptin concentration.
Sertraline CarBAMazepine could decrease Sertraline serum concentrations
Siltuximab Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
SUFentanil CYP3A4 Inducers Strong may reduce the serum concentrations of SUFentanil.
Sulthiame CarBAMazepine could lower the serum concentrations of Sulthiame.
Tetrahydrocannabinol CYP3A4 Inducers Strong may reduce the serum Tetrahydrocannabinol concentration.
Tetrahydrocannabinol, and Cannabidiol Strong CYP3A4 Inducers may reduce the serum concentrations of Tetrahydrocannabinol or Cannabidiol.
Thiazide and Thiazide -Like Diuretics CarBAMazepine may have an adverse/toxic effect that can be increased. Hyponatremia may be more likely.
Thiothixene CarBAMazepine could lower the serum concentrations of Thiothixene.
Thyroid Products CarBAMazepine could lower serum levels of Thyroid Products.
Tocilizumab Could lower serum concentrations of CYP3A4 substrates (High Risk with Inducers).
Tricyclic Antidepressants CarBAMazepine could lower serum levels of Tricyclic Antidepressants.
Tropisetron CYP3A4 Inducers Strong may reduce Tropisetron serum concentration.
Udenafil CYP3A4 Inducers Strong may reduce the serum level of Udenafil.
Valproate Products It is possible to increase serum levels of CarBAMazepine's active metabolite(s). The parent carbamazepine levels may fluctuate between increased, decreased or unchanged. CarBAMazepine can decrease serum Valproate Products concentrations.
Vecuronium CarBAMazepine could lower the serum level of Vecuronium
Ziprasidone CarBAMazepine could lower the serum Zirazdone concentration.
Zolpidem CarBAMazepine may increase the CNS depressant effects. CarBAMazepine can decrease Zolpidem serum concentration. Management: Pay attention to the zolpidem response. Men who are taking carbamazepine and Intermezzo brand sublingual Zolpidem should reduce their dose to 1.75mg. For women, such dose adjustments are not recommended.
Zuclopenthixol CYP3A4 Inducers Strong may reduce the serum concentrations of Zuclopenthixol.

Risk Factor D (Regard therapy modification)
Abiraterone Acetate Strong CYP3A4 Inducers may reduce serum Abiraterone Acetate concentrations. Avoid when possible. If this combination is not possible, increase the abiraterone-acetate dose frequency from once daily up to twice daily while taking concomitant abiraterone.
Acalabrutinib CYP3A4 Inducers Strong may reduce the serum concentrations of Acalabrutinib. Patients taking acalabrutinib should not be given strong CYP3A stimulants. If it is impossible to avoid strong CYP3A stimulators, increase the daily dose to 200 mg.
Adenosine CarBAMazepine could increase the toxic/adverse effects of Adenosine. In particular, higher degrees of heart block could be more likely. Patients who are taking carbamazepine should be given a lower dose of adenosine.
Afatinib CarBAMazepine can decrease Afatinib serum concentration. Management: If you are unable to stop carbamazepine for a prolonged period of time, increase the afatinib dosage by 10 mg. Canadian labeling states that you should avoid combination therapy if at all possible.
ARIPiprazole Strong CYP3A4 Inducers may reduce serum ARIPiprazole concentrations. Management: Increase the oral dose of aripiprazole and monitor closely. If the inducer is stopped, reduce oral aripiprazole dosage to 10-15 mg/day for adults. Extended-release injectable aripiprazole should not be used for longer than 14 days.
ARIPiprazole CYP3A4 Inducers Strong may reduce serum levels of active metabolites of ARIPiprazole Laroxil. Treatment: Patients who have taken the 441 mg of aripiprazole Lauroxil for 14 days or more may increase their dose to 662mg if they are given a strong CYP3A4 inducer. Patients who take higher doses of aripiprazole are not required to adjust their dose.
Bictegravir CarBAMazepine can decrease serum levels of Bictegravir. Management: If possible, consider using an anticonvulsant that is concurrently bictegravir and emtricitabine. Monitor closely for signs of decreased antiviral efficacy if the combination is necessary.
Brexpiprazole CYP3A4 Inducers Strong may reduce the serum concentrations of Brexpiprazole. Management: Brexpiprazole should be gradually increased in dose over a period of one to two weeks if taken with a strong CYP3A4 Inducer.
BusPIRone BusPIRone serum concentration may be decreased by strong CYP3A4 inducers. Management: You may consider alternatives to this combination. If these agents must be administered together, keep an eye on patients to monitor for decreased buspirone effects. Increase buspirone dosages as necessary.
Cabozantinib CYP3A4 Inducers Strong may reduce the serum Cabozantinib concentration. If possible, avoid strong CYP3A4 inducers when taking cabozantinib. Combinations of cabozantinib products should be avoided. Dose adjustments may be necessary depending on the product and indication. For more information, see monograph
Calcium Channel Blockers (Dihydropyridine). CarBAMazepine can increase metabolism of Calcium Channel Blockers (Dihydropyridine). Treatment: Patients who are taking concomitant carbamazepine should consider dose adjustments for calcium channel blockers (CCB). Nimodipine Canadian labeling prohibits concurrent use of carbamazepine. Clevidipine is an exception.
Calcium Channel Blockers (Nondihydropyridine). CarBAMazepine may increase serum concentrations. CarBAMazepine can decrease serum calcium channel blockers (Nondihydropyridine) concentrations. Management: Reduce carbamazepine dosage and start nondihydropyridine calcium channels blockers. You should monitor for the increased toxic effects of carbamazepine as well as reduced therapeutic effects from calcium channel blockers.
Canagliflozin CarBAMazepine can decrease Canagliflozin serum concentration. Management: Increase canagliflozin dosage to 300 mg/day for patients with an estimated GFR of 60 mL/min/1.73m2 or greater who can tolerate 100 mg/day canagliflozin and need more glycemic control. Patients with GFRs between 45-60 mL/min/1.73m2 should consider alternatives.
Caspofungin Caspofungin serum concentration may be decreased by inducers of drug clearance. Management: Increase caspofungin dosage to 70 mg per day for adults, or 70 mg/m for children, if coadministered alongside known inducers.
Clarithromycin CarBAMazepine could increase serum levels of active metabolites of Clarithromycin. Clarithromycin could increase CarBAMazepine's serum concentration. Clarithromycin may be less effective when CarBAMazepine is added. Management: If possible, consider alternatives to this combination. Monitor for elevated carbamazepine toxicities/toxicities, and reduced clarithromycin efficacy if combined.
CycloSPORINE Systemic CarBAMazepine can decrease the serum level of CycloSPORINE Systemic. If you are taking cyclosporine with carbamazepine, be sure to monitor your serum for any decreases in cyclosporine levels and therapeutic effects. To maintain sufficient serum concentrations, it is likely that you will need to take higher doses of cyclosporine.
Strong CYP3A4 inhibitors Might decrease metabolism of CYP3A4 substrates (High Risk with Inhibitors).
CYP3A4 Substrates - High risk with Inducers Strong CYP3A4 Inducers may increase metabolism of CYP3A4 substrates (High Risk with Inducers). Management: You may consider a different drug to replace one of the interacting drugs. Some combinations might be contraindicated. Refer to the appropriate manufacturer labeling. Exceptions: Benzhydrocodone, Buprenorphine, CarBAMazepine and Etizolam; HYDROcodone. TraMADol. Zolpidem.
Dabrafenib High risk of Inducers causing a decrease in serum CYP3A4 substrates. Management: If possible, seek alternatives to the CYP3A4 substrate. Concomitant therapy should be avoided if possible. Monitor the clinical effects of the substrate carefully (especially therapeutic effects).
Dasatinib CYP3A4 Inducers Strong may reduce the serum level of Dasatinib. Avoid if possible. Consider increasing the dose of dasatinib if necessary. Also, be sure to monitor your clinical response and toxicities.
Dexamethasone Systemic CYP3A4 Inducers, Strong may cause a decrease in serum Dexamethasone concentration (Systemic). Management: Patients who are receiving strong CYP3A4 Inducers (Strong) should consider increasing their dexamethasone dosage and closely monitor for decreased steroid efficacy.
Dolutegravir Dolutegravir serum concentration may be decreased by CarBAMazepine. Use carbamazepine and dolutegravir together to increase the dose. If possible, patients with suspected or confirmed integrase-strand inhibitor resistance should consider an alternative to carbamazepine.
DOXOrubicin Conventional CYP3A4 Inducers Strong may reduce the serum DOXOrubicin concentration (Conventional). Management: Avoid strong CYP3A4 inducers for patients receiving doxorubicin. These combinations should be avoided according to one U.S. manufacturer, Pfizer Inc.
DOXOrubicin Conventional P-glycoprotein/ABCB1 inducers may reduce the serum level of DOXOrubicin (Conventional). Management: If possible, seek alternatives to P-glycoprotein inducers for patients who have been treated with doxorubicin. These combinations should be avoided according to one U.S. manufacturer, Pfizer Inc.
Doxycycline CarBAMazepine could lower the serum level of Doxycycline.
Edoxaban CarBAMazepine can decrease serum Edoxaban concentrations. Management: It is best to avoid the combination of carbamazepine with edoxaban.
Enzalutamide CYP3A4 Inducers Strong may reduce the serum Enzalutamide concentration. Management: If possible, consider using an alternative agent with a low or no CYP3A4-induction potential. This combination can be avoided by increasing the dosage of enzalutamide to 160 mg daily or 240 mg daily if necessary.
Enzalutamide High risk of Inducers causing a decrease in serum concentrations of CYP3A4 substrates. Management: Avoid concurrent use of enzalutamide and CYP3A4 substrates with a narrow therapeutic index. You should exercise caution when using enzalutamide or any other CYP3A4 sub-substance.
Eravacycline Strong CYP3A4 inducers may cause a decrease in serum Eravacycline concentration. Management: Combine strong CYP3A4 inducers with eravacycline to increase the dose to 1.5 mg/kg once every 12 hours.
Erlotinib CYP3A4 Inducers Strong may reduce the serum Erlotinib concentration. If possible, avoid combination. Combination: If necessary, increase the erlotinib dosage by 50 mg every 2 weeks, as tolerated. Maximum 450 mg/day
Systemic Erythromycin Increased serum CarBAMazepine concentrations may occur. Management: You may consider other antimicrobial therapies in conjunction with carbamazepine. Monitor for elevated carbamazepine toxicities if combined
Contraceptive: Estrogen Derivatives CarBAMazepine can decrease the therapeutic effects of Estrogen Derivatives. It is possible to have contraceptive failure. Management: It is recommended to use a nonhormonal contraceptive.
Etoposide Strong CYP3A4 Inducers may reduce the serum level of Etoposide. Treatment: If possible, consider alternatives to strong CYP3A4 inducing drugs for patients who are taking etoposide. Patients should be closely monitored for decreased etoposide response or increased etoposide dosage.
Etoposide phosphate Strong CYP3A4 Inducers may reduce the serum level of Etoposide Phosphate. Treatment: If possible, consider alternatives to strong CYP3A4inducing drugs for patients who are receiving etoposide phosphate. These combinations should not be avoided. Patients must be closely monitored for a diminished etoposide-phosphate response.
Everolimus CYP3A4 Inducers Strong may reduce the serum Everolimus concentration. If possible, avoid concurrent use of strong CYP3A4 inducers. Double the daily everolimus dose if coadministration is not possible. Use increments of 5mg or less. If everolimus serum levels are indicated, monitor them closely.
Exemestane CYP3A4 Inducers Strong may reduce the serum Exemestane concentration. Management: Exemestane U.S. product labels recommend a 50 mg/day dose for patients who are concurrently taking strong CYP3A4 inducers. Canadian product labels do not recommend adjusting the dose for concurrent strong CYP3A4 inducers.
Ezogabine CarBAMazepine can decrease serum Ezogabine concentrations. Management: Increase the dose of ezogabine when you add carbamazepine. For evidence of effective ezogabine therapy, closely monitor patients who use the combination.
Felbamate CarBAMazepine could decrease the serum concentrations of Felbamate. CarBAMazepine may be decreased by Felbamate. Treatment: Patients on carbamazepine should be given felbamate at 1200mg/day in divided doses, 3-4 times per day. Carbamazepine dosage should be reduced by 20%. Monitoring for decreased concentrations or effects of either drug.
Fosphenytoin Could decrease serum CarBAMazepine concentration. CarBAMazepine can decrease the serum level of Fosphenytoin. CarBAMazepine could increase Fosphenytoin's serum concentration. It may be due to competitive inhibition at the sites of metabolism.
Gefitinib Gefitinib serum concentration may be decreased by strong CYP3A4 inducers. Treatment: If there are no severe adverse reactions, increase the dose of gefitinib to 500 mg daily for patients who have been treated with strong CYP3A4 inducers. The 250 mg dose can be resumed 7 days after the strong inducer has been discontinued. Monitor your clinical response.
GuanFACINE CYP3A4 Inducers Strong may reduce the serum GuanFACINE. Management: Concomitant therapy using strong CYP3A4 inducers may increase the guanfacine dosage by as much as twice. If strong CYP3A4 inducer therapy is just starting, gradually increase the guanfacine dosage over 1-2 weeks.
Imatinib CYP3A4 Inducers Strong may reduce the serum concentrations of Imatinib. Management: If possible, avoid concurrent use of imatinib and strong CYP3A4 inducers. If this combination is necessary, increase the imatinib dosage by at least half and closely monitor the patient's response.
Ixabepilone Strong CYP3A4 Inducers may reduce serum Ixabepilone concentrations. This combination should be avoided whenever possible. Consider using this combination if you must. As tolerated, increase the ixabepilone dosage from 40 mg/m up to 60 mg/m over a 4-hour period.
LamoTRIgine CarBAMazepine may have an adverse/toxic effect. CarBAMazepine could increase LamoTRIgine metabolism
Larotrectinib CYP3A4 Inducers (Strong), may reduce the serum level of Larotrectinib. Management: Do not use strong CYP3A4 inducers in combination with larotrectinib. Double the larotrectinib dosage if this combination is not possible. After stopping the inducer, reduce the dose to the previous dose for a period of 3-5 times the half-life.
Linagliptin CYP3A4 Inducers Strong may reduce serum Linagliptin. If linagliptin is being used, it is a good idea to consider an alternative. Patients should be closely monitored if this combination is used to determine if there are any signs of decreased effectiveness of linagliptin.
Linagliptin The serum level of Linagliptin may be decreased by P-glycoprotein/ABCB1 inducers. Treatment: If linagliptin is being used, it is a good idea to consider an alternative. Patients should be closely monitored if this combination is used to determine if there are any signs of decreased effectiveness of linagliptin.
Lopinavir CarBAMazepine can decrease Lopinavir serum concentration. Combining these agents may require higher doses of lopinavir. Use lopinavir/ritonavir combination with carbamazepine only once daily. This combination should be used to monitor the therapeutic response of all patients.
Manidipine CYP3A4 Inducers Strong may reduce the serum Manidipine concentration. Management: Avoid concomitant intake of strong CYP3A4 inducers and manidipine. Combine manidipine and strong CYP3A4 inducers carefully to avoid decreased manidipine effects or loss of efficacy. Manidipine dosages may need to be increased.
Maraviroc CYP3A4 Inducers Strong may reduce the serum concentrations of Maraviroc. Management: When using strong CYP3A4 inducers, increase maraviroc adult dosage to 600mg twice daily. Patients who are also taking strong CYP3A4 inhibitors will not be affected by this change. Patients with CrCl below 30 mL/min should not take maraviroc when they are receiving strong CYP3A4 inhibitors.
Mefloquine Anticonvulsants may have a lower therapeutic effect. The serum concentrations of Anticonvulsants may be decreased by Mefloquine. Management: Mefloquine should not be used for malaria prophylaxis if there are convulsion history. Concurrent use of anticonvulsants should be closely monitored.
MethylPREDNISolone Strong CYP3A4 inducers may cause a decrease in serum levels of MethylPREDNISolone. Management: Patients who are taking strong CYP3A4 Inducers (Strong) should be aware of the possibility of a rise in methylprednisolone dosage and closely monitor for decreased steroid effectiveness.
Mirodenafil Strong CYP3A4 inducers (Strong) can decrease serum Mirodenafil concentration. Management: Avoid the use of strong CYP3A4 inducers and mirodenafil together. Monitor for decreased mirodenafil effect if combined. To achieve the desired effects, mirodenafil dosage increases may be necessary.
Mitotane High risk of Inducers causing a decrease in serum concentrations of CYP3A4 substrates. Treatment: Patients receiving mitotane may require significant adjustments in the dosage of CYP3A4 Substrates.
Osimertinib Osimertinib serum concentration may be decreased by strong CYP3A4 inducers.
Oxcarbazepine CarBAMazepine could decrease serum levels of OXcarbazepine's active metabolite(s). Concentrations of the active 10-monohydroxy metabolite might be decreased. Management: Increase the adult oxcarbazepine extended-release tablet (OxtellarXR) dosage to 900 mg/day. There are no recommendations for other oxcarbazepine formulas.
Perampanel CarBAMazepine can decrease Perampanel's serum concentration. Perampanel administration with carbamazepine: Management: Increase the starting dose of perampanel to 4 mg/day. This combination should be closely monitored for any changes in carbamazepine therapy.
Phenytoin CarBAMazepine could decrease the serum level of Phenytoin. CarBAMazepine may be less effective if there is Phenytoin. CarBAMazepine could increase the serum level of Phenytoin. It may be due to competitive inhibition at the sites of metabolism.
Pitolisant High risk of Inducers causing a decrease in serum concentrations of CYP3A4 substrates Management: Avoid combining pitolisant and a CYP3A4 substrat with a low therapeutic index. Pitolisant should not be combined with other CYP3A4 sub-substances.
Contraceptive Progestins CarBAMazepine can decrease the therapeutic effects of Progestins (Contraceptive). It is possible to have contraceptive failure. Management: It is recommended to use nonhormonal contraceptives.
Protease inhibitors CarBAMazepine could increase metabolism of Protease Inhibitors. CarBAMazepine metabolism may be decreased by Protease Inhibitors
QUEtiapine Increased serum levels of CarBAMazepine's active metabolite(s). CarBAMazepine can decrease serum concentrations of QUEtiapine. Quetiapine Management
To maintain therapeutic benefits, a dose increase of up to 5 times the usual dose may be necessary. After quitting carbamazepine, reduce the quetiapine dosage to the regular dose. QuiNINE: CarBAMazepine can decrease QuiNINE's serum concentration. QuiNINE could increase CarBAMazepine's serum concentration.
Radotinib CYP3A4 Inducers Strong may reduce the serum level of Radotinib. Management: If possible, consider alternatives as the chance of Radotinib treatment failing may increase.
RisperiDONE Strong CYP3A4 inducers may cause a decrease in serum RisperiDONE. Management: If a strong CYP3A4 inducer is used, consider increasing the oral risperidone dose (but not more than twice the original dose). Patients on IM risperidone should consider increasing their IM doses or taking supplementary oral risperidone.
Rolapitant Rolapitant serum concentrations may be decreased by strong CYP3A4 inducers. Patients who are dependent on strong CYP3A4 inducers should be avoided. Monitoring for a reduced rolapitant response, and the need to use alternative or additional antiemetic therapies even if these inducers are used for a shorter time.
Sirolimus CYP3A4 Inducers Strong may reduce the serum sirolimus concentration. Management: If possible, avoid sirolimus and strong CYP3A4 inducers. Monitor for reduced serum sirolimus levels if combined. To prevent sirolimus levels below therapeutic levels, sirolimus dose increases may be required.
St John's Wort High risk of Inducers causing a decrease in serum CYP3A4 Substrates. Management: You may consider a different drug to replace one of the interacting drugs. Some combinations might be contraindicated. Refer to the manufacturer's label.
SUNItinib CYP3A4 Inducers Strong may reduce the serum concentrations of SUNItinib. Avoid if possible. Consider increasing sunitinib dosage and closely monitoring clinical responses and toxicities if this combination is not possible.
Tadalafil CYP3A4 Inducers Strong may reduce the serum concentrations of Tadalafil. Management: Monitor for decreased effectiveness and do not adjust the dose. Patients who are taking a strong CYP3A4 stimulant should not use tadalafil to treat pulmonary arterial hypertension.
Tamoxifen CYP3A4 Inducers Strong may lower the serum concentrations active metabolites of Tamoxifen. CYP3A4 Strong Inducers may lower the serum Tamoxifen concentration. Management: There are alternatives to tamoxifen and strong CYP3A4 inducers. Monitor for decreased therapeutic effects of Tamoxifen if the combination is not possible.
Temsirolimus CarBAMazepine could decrease Temsirolimus serum concentrations. Sirolimus' active metabolite may also be reduced (or even increased). Management: The Temsirolimus prescribing info recommends against coadministration of strong CYP3A4 inducers like carbamazepine. However, if concurrent therapy is required, an increase in temsirolimus adults to 50 mg/week may be considered.
Theophylline Derivatives CarBAMazepine could decrease serum levels of Theophylline derivatives. CarBAMazepine may be less effective in reducing serum levels of Theophylline derivatives. Management: If possible, look for alternatives. Monitor closely for decreased therapeutic effects and serum concentrations of these agents when they are combined. Dyphylline is an exception.
TiaGABine CYP3A4 Inducers Strong may reduce the serum TiaGABine concentration. Patients who are taking strong CYP3A4 inducers will need to be administered approximately 2-fold more tiagabine and a faster dose titration.
Topiramate CarBAMazepine could lower the serum concentrations of Topiramate.
Vemurafenib CYP3A4 Inducers Strong may reduce the serum concentrations of Vemurafenib. Management: Vemurafenib should not be used in conjunction with a strong CYP3A4 stimulator. If possible, replace it with another agent. If a strong CYP3A4 inducer is necessary and cannot be avoided, the dosage of vemurafenib can be increased to 240 mg (1 tablet).
Vilazodone CYP3A4 Inducers Strong may cause a decrease in the serum Vilazodone concentration. Management: Increase the dose of vilazodone by up to 2-fold, but not exceeding 80 mg/day, based on responses in patients who have been receiving strong CYP3A4 inducers over a period of > 14 days. After discontinuation of inducers, reduce the dose to the original vilazodone level by 1-2 weeks.
Vitamin K antagonists (eg warfarin) CarBAMazepine can decrease serum Vitamin K Antagonists. Management: Watch for signs of decreased INR or effects from vitamin K antagonists when carbamazepine has been started/dose increased. If carbamazepine has been discontinued/dose reduced, monitor for increased INR. Adjustments in Warfarin dosage will probably be necessary.
Vortioxetine CYP3A4 Inducers Strong may reduce the serum Vortioxetine concentration. Management: If vortioxetine is taken with strong drug metabolism stimulators for longer than 14 days, you should not increase the dose by more than three times. After stopping the strong inducer, the vortioxetine dosage should be reduced to its normal level within 14 days.
Zaleplon CYP3A4 Inducers Strong may reduce the serum level of Zaleplon. Management: If patients are receiving strong CYP3A4 inducers, it is worth considering the use of another hypnotic that does not get metabolized by CYP3A4. Monitor for decreased effectiveness if zalephon is used in combination with a strong CYP3A4 stimulator.

Risk Factor X (Avoid Combination)
Abemaciclib Abemaciclib serum concentration may be decreased by strong CYP3A4 inducers.
Antihepaciviral combination products Strong CYP3A4 Inducers may reduce serum Antihepaciviral Combination Products.
Apixaban CYP3A4 Inducers Strong may reduce Apixaban serum concentration.
Apremilast Apremilast serum concentration may be decreased by strong CYP3A4 inducers.
Aprepitant Aprepitant serum concentrations may be decreased by strong CYP3A4 inducers.
Artemether CYP3A4 Inducers Strong may reduce serum levels of active metabolites of Artemether. Dihydroartemisinin concentrations could be decreased. CYP3A4 Inducers Strong may reduce the serum Artemether concentration.
Asunaprevir CYP3A4 Inducers Strong may reduce Asunaprevir serum concentration.
Axitinib CYP3A4 Inducers Strong may reduce the serum concentrations of Axitinib.
BCG (Intravesical). Myelosuppressive agents may reduce the therapeutic effects of BCG (Intravesical).
Bedaquiline CYP3A4 Inducers Strong may reduce the serum concentrations of Bedaquiline.
Bortezomib Bortezomib serum concentration may be decreased by CYP3A4 Inducers.
Bosutinib CYP3A4 Inducers Strong may reduce the serum Bosutinib concentration.
Brigatinib CYP3A4 Inducers Strong may reduce the serum Brigatinib concentration.
Cariprazine CYP3A4 Inducers Strong may reduce serum Cariprazine concentrations.
Ceritinib CYP3A4 Inducers Strong may reduce Ceritinib serum concentration.
Cladribine May increase the myelosuppressive effects of myelosuppressive agents.
CloZAPine CloZAPine may have a higher myelosuppressive activity due to CarBAMazepine. The combination of these drugs may increase the risk of bone loss due to their independent myelosuppressive actions. CloZAPine serum concentrations may be decreased by CarBAMazepine
Cobicistat CarBAMazepine could lower the serum concentrations of Cobicistat.
Cobimetinib CYP3A4 Inducers Strong may reduce the serum Cobimetinib concentration.
Conivaptan High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
Copanlisib CYP3A4 Inducers Strong may reduce the serum level of Copanlisib.
Crizotinib CYP3A4 Inducers Strong may reduce Crizotinib serum concentration.
Dabigatran Etexilate The serum concentration of Dabigatran Etexilate may be decreased by P-glycoprotein/ABCB1 inducers. Management: If possible, avoid concurrent use of dabigatran and P-glycoprotein Inducers.
Daclatasvir CYP3A4 Inducers Strong may reduce the serum level of Daclatasvir.
Dasabuvir CYP3A4 Inducers Strong may reduce serum Dasabuvir concentration.
Deferiprone Deferiprone may have a neutropenic effect that myelosuppressive agents can increase.
Deflazacort CYP3A4 Inducers Strong may reduce serum levels of active metabolites of Deflazacort.
Delamanid CYP3A4 Inducers Strong may reduce the serum concentrations of Delamanid.
Delavirdine CarBAMazepine could lower the serum level of Delavirdine.
Dienogest Strong CYP3A4 Inducers may cause a decrease in serum levels of Dienogest. Management: Dienogest should not be used for contraception if you are using CYP3A4 Inducers (Strong) and for at most 28 days following the discontinuation of a CYP3A4 inducer. During this period, an alternative method of contraception should also be used.
Dipyrone May increase the toxic/adverse effects of Myelosuppressive Agents. In particular, there may be an increase in the risk of pancytopenia and agranulocytosis.
Doravirine CYP3A4 Inducers Strong may reduce the serum concentrations of Doravirine.
Dronedarone CYP3A4 Inducers Strong may reduce Dronedarone serum concentrations
Duvelisib CYP3A4 Inducers Strong may reduce serum levels of Duvelisib.
Efavirenz Efavirenz may be less soluble in CarBAMazepine. Efavirenz could decrease the serum concentrations of CarBAMazepine.
Elbasvir CYP3A4 Inducers Strong may reduce the serum Elbasvir concentration.
Eliglustat CYP3A4 Inducers Strong may reduce the serum Eliglustat concentration.
Elvitegravir CarBAMazepine could lower the serum concentrations of Elvitegravir.
Encorafenib CYP3A4 Inducers Strong may reduce the serum Encorafenib concentration.
Etravirine CYP3A4 Inducers Strong may reduce the serum level of Etravirine.
Flibanserin Flibanserin serum concentration may be decreased by strong CYP3A4 inducers.
Fosaprepitant CYP3A4 Inducers Strong may reduce the serum concentrations of Fosaprepitant. Specifically, CYP3A4 Boosters (Strong), may lower serum levels of active metabolite aprepitant.
Fosnetupitant CYP3A4 Inducers Strong may reduce serum levels of active metabolites of Fosnetupitant.
Fostamatinib CYP3A4 Inducers Strong may reduce serum levels of Fostamatinib's active metabolite(s).
Fusidic Acid (Systemic). High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
Gemigliptin CYP3A4 Inducers Strong may lower serum concentrations for the active metabolite(s), Gemigliptin. CYP3A4 Inducers Strong may lower the serum concentrations of Gemigliptin.
Gilteritinib The serum concentration of Gilteritinib may be decreased by combining inducers of CYP3A4 or P-glycoprotein.
Glasdegib CYP3A4 Inducers Strong may reduce the serum Glasdegib concentration.
Pibrentasvir and Glecaprevir CarBAMazepine could decrease the serum concentrations of Glecaprevir or Pibrentasvir.
Grazoprevir CYP3A4 Inducers Strong may reduce the serum concentrations of Grazoprevir.
Ibrutinib CYP3A4 Inducers Strong may reduce the serum Ibrutinib concentration.
Idelalisib CYP3A4 Inducers Strong may reduce the serum concentrations of Idelalisib.
Idelalisib High risk of Inhibitors causing an increase in serum CYP3A4 Substrates concentrations
Irinotecan Products CYP3A4 Inducers Strong may reduce serum levels of active metabolites of Irinotecan Products. Specifically, the serum concentrations may decrease for SN-38. CYP3A4 Inducers, Strong may reduce serum concentrations of Irinotecan Products.
Isavuconazonium sulfate CYP3A4 Strong may cause a decrease in serum levels of active metabolites of Isavuconazonium Sulfate. Specifically, CYP3A4 Activators (Strong) could decrease serum isavuconazole concentrations.
Itraconazole CYP3A4 Inducers Strong may reduce the serum concentrations of Itraconazole.
Ivabradine CYP3A4 Inducers Strong may reduce the serum Ivabradine concentration.
Ivacaftor CYP3A4 Inducers Strong may reduce the serum Ivacaftor concentration.
Ivosidenib CYP3A4 Inducers Strong may reduce the serum concentrations of Ivosidenib.
Ixazomib CYP3A4 Inducers Strong may reduce the serum Ixazomib concentration.
Lapatinib CYP3A4 Inducers Strong may reduce the serum level of Lapatinib. Management: If therapy overlap is not possible, you may consider gradually increasing lapatinib doses from 1,250 mg/day to 4,500 mg/day for HER2 positive metastatic cancer or 1,500 mg/day to 5,500 mg/day for hormone receptor/HER2 positive breast carcinoma.
Ledipasvir The serum concentration of Ledipasvir may be decreased by P-glycoprotein/ABCB1 inducers.
Lorlatinib CYP3A4 Inducers Strong may reduce the serum Lorlatinib concentration.
Lumefantrine CYP3A4 Inducers Strong may reduce the serum level of Lumefantrine.
Lurasidone CYP3A4 Inducers Strong may reduce serum Lurasidone concentrations
Macimorelin CYP3A4 Inducers Strong may reduce the serum Macimorelin concentration.
Macitentan CYP3A4 Inducers Strong may reduce the serum Macitentan concentration.
Midostaurin CYP3A4 Inducers Strong may reduce serum Midostaurin concentrations
MiFEPRIStone CYP3A4 Inducers, Strong may reduce serum concentrations of MiFEPRIStone.
Monoamine Oxidase inhibitors CarBAMazepine can increase the toxic/adverse effects of Monoamine Oxidase Ihibitors. Management: Do not use carbamazepine concurrently with monoamine oxidase inhibitor treatment.
Naldemedine CYP3A4 Inducers Strong may reduce the serum Naldemedine concentration.
Naloxegol CYP3A4 Inducers Strong may reduce the serum Naloxegol concentration.
Nefazodone Could increase serum CarBAMazepine concentrations. The active CarBAMazepine Epoxide metabolite concentrations may also be decreased. The serum concentration of Nefazodone could be decreased by CarBAMazepine. It is possible that concentrations of active Nefazodonemetabolites could be decreased.
Neratinib CYP3A4 Inducers Strong may reduce the serum level of Neratinib.
Netupitant CYP3A4 Inducers Strong may reduce the serum Netupitant concentration.
Nevirapine CarBAMazepine could lower the serum level of Nevirapine.
NIFEdipine CYP3A4 Inducers Strong may reduce serum levels of NIFEdipine.
Nilotinib CYP3A4 Inducers Strong may reduce the serum Nilotinib concentration.
NiMODipine CYP3A4 Inducers Strong may reduce the serum NiMODipine concentration.
Nintedanib The serum concentrations of Nintedanib may be decreased by using Combined Inducers of CYP3A4 or P-glycoprotein.
Nisoldipine CYP3A4 Inducers Strong may reduce the serum Nisoldipine concentration.
Olaparib CYP3A4 Inducers Strong may reduce the serum Olaparib concentration.
Palbociclib CYP3A4 Inducers Strong may reduce the serum level of Palbociclib.
Panobinostat CYP3A4 Inducers Strong may reduce the serum Panobinostat concentration.
PAZOPanib CYP3A4 Inducers Strong may reduce the serum concentrations of PAZOPanib.
Piperaquine Piperaquine serum concentration may be decreased by strong CYP3A4 inducers.
PONATinib CYP3A4 Inducers Strong may reduce the serum level of PONATinib.
Praziquantel CYP3A4 Inducers Strong may reduce the serum concentrations of Praziquantel. Management: Praziquantel with strong CYP3A4 Inducers is not recommended. Stop taking rifampin four weeks before starting praziquantel treatment. After praziquantel is completed, rifampin can be resumed.
Ranolazine Ranolazine serum concentration may be decreased by strong CYP3A4 inducers.
Regorafenib Regorafenib serum concentration may be decreased by strong CYP3A4 inducers.
Ribociclib CYP3A4 Inducers Strong may reduce Ribociclib serum concentrations.
Rilpivirine CarBAMazepine could lower the serum level of Rilpivirine.
Rivaroxaban Rivaroxaban serum concentration may be decreased by strong CYP3A4 inducers.
Roflumilast Roflumilast serum concentration may be decreased by strong CYP3A4 inducers. Management: The Roflumilast U.S. prescribing advice recommends against combining strong CYP3A4 inducers with roflumilast. Canadian product monographs do not make such a recommendation, but note that such agents could reduce roflumilast therapeutic effect.
RomiDEPsin CYP3A4 Inducers Strong may reduce serum RomiDEPsin concentrations.
Simeprevir Simeprevir serum concentration may be decreased by strong CYP3A4 inducers.
Sofosbuvir The serum concentration of Sofosbuvir may be decreased by P-glycoprotein/ABCB1 inducers.
Sonidegib Sonidegib serum concentration may be decreased by CYP3A4 Inducers.
SORAfenib CYP3A4 Inducers Strong may reduce serum SORAfenib.
Stiripentol Increases the serum concentration of CarBAMazepine.
Tasimelteon CYP3A4 Inducers Strong may reduce the serum concentrations of Tasimelteon.
Tenofovir Alafenamide CarBAMazepine could lower the serum Tenofovir Alafenamide concentration.
Ticagrelor CYP3A4 Inducers Strong may lower serum levels of active metabolites of Ticagrelor. Ticagrelor serum concentration may be decreased by CYP3A4 inducers (Strong).
Tofacitinib CYP3A4 Inducers Strong may reduce the serum Tofacitinib concentration.
Tolvaptan Tolvaptan serum concentration may be decreased by strong CYP3A4 inducers. Management: Concurrent use may require increased doses of Tolvaptan, with close monitoring for toxicology and clinical response.
Toremifene CYP3A4 Inducers Strong may reduce the serum Toremifene concentration.
Trabectedin CYP3A4 Inducers Strong may reduce serum Trabectedin concentrations
TraMADol CarBAMazepine may increase the CNS depressant effects. TraMADol could decrease the therapeutic effects of CarBAMazepine. CarBAMazepine could decrease TraMADol's serum concentration.
Ulipristal CYP3A4 Inducers Strong may reduce the serum level of Ulipristal.
Valbenazine CYP3A4 Inducers Strong may reduce the serum Valbenazine concentration.
Vandetanib Vandetanib serum concentration may be decreased by strong CYP3A4 inducers.
Velpatasvir Moderate CYP2B6 Inducers may reduce the serum Velpatasvir concentration.
Velpatasvir Velpatasvir serum concentration may be decreased by strong CYP3A4 inducers.
Velpatasvir Velpatasvir serum concentration may be decreased by P-glycoprotein/ABCB1 inducers.
Venetoclax CYP3A4 Inducers Strong may reduce the serum Venetoclax concentration.
VinCRIStine - (Liposomal CYP3A4 Inducers Strong may reduce the serum VinCRIStine (Liposomal) concentration.
VinCRIStine (Liposomal The serum VinCRIStine (Liposomal) concentration may be decreased by P-glycoprotein/ABCB1 inducers
Vinflunine Vinflunine serum concentrations may be decreased by strong CYP3A4 inducers.
Vorapaxar CYP3A4 Inducers Strong may reduce the serum Vorapaxar concentration.
Voriconazole CarBAMazepine could lower the serum concentrations of Voriconazole.
Voxilaprevir Voxilaprevir serum concentration may be decreased by strong CYP3A4 inducers.

Monitoring parameters:

 Baseline and then periodic monitoring of the following parameters should be done:

  • Complete blood counts with platelets differential counts
  • Reticulocyte counts
  • Serum iron
  • liver and renal function tests
  • Urinalysis
  • Serum sodium
  • Ophthalmic exam and intraocular pressure.

Lipid profile, serum carbamazepine levels, thyroid function tests, and pregnancy test may be ordered only when appropriate. Patients should be observed for excessive sedation, suicidal tendencies, depression, and behavioral changes.

How to administer Carbamazepine?

Administer the immediate-release tablets with food. The suspension must be shaken well before administration and given thrice or four times a day because of the higher peak and lower trough levels. The tablets may be given twice daily. The carbamazepine suspension should not be taken concomitantly with other liquid medicinal agents.

The extended-release tablets should be either swallowed whole without crushing or chewing it or the capsule may be opened and the beads sprinkled over the food such as a teaspoon of applesauce and swallowed. The extended-release tablets should be inspected for damage before administering it. The intravenous formulation may be administered intravenously over 30 minutes. 

Mechanism of action of Carbamazepine:

  • Carbamazepine is anticonvulsant, anticholinergic and antineuralgic.
  •  Apart from its effects on the muscles, which result in muscle relaxation, it also has antidiuretic and antimanic, antidepressant and antidepressant properties.
  • It reduces synaptic transmission and neuronal releases by reducing sodium ions crossing cell membranes.
  • It stimulates the production of the anti-diuretic hormonal hormone and increases its effectiveness by encouraging the reabsorption water.

AbsorptionThe absorption of carbamazepine via the GI tract is slow. It is 75 to 90 percent protein bound. It isMetabolizedBy cytochrome P450 3A4 to active metabolite. It causes liver enzymes to be activated and the half-life of this drug decreases with time. BioavailabilityIs 75% to 85 % Eliminating half-lifeVariable, but can range from 30-60 hours. 

The active metabolite has a half-life of approximately 34 hours. When plasma concentration reaches its peakUnpredictable, but can vary between 1.5 hours for suspension, 4 to 5 hours for tablet and 12 to 26 hours with extended release tablet. ExcretionIt is mostly via urine (72%).    

International brands of Carbamazepine:

  • APO-CarBAMazepine
  • DOM-CarBAMazepine
  • DOM-CarBAMazepine CR
  • Mazepine
  • MYLAN-CarBAMazepine
  • PMS-CarBAMazepine
  • PMS-CarBAMazepine CR
  • PMS-CarBAMazepine-CR
  • SANDOZ CarBAMazepine CR
  • SANDOZ CarBAMazepine
  • TARO-CarBAMazepine
  • TEGretol
  • TEGretol CR
  • TEVA-Carbamazepine
  • Actinerval
  • Anleptic 200 CR
  • Apo-Carbamazepine
  • Arbateg
  • Arbil
  • Azepal
  • Bamgetol
  • Brucarcer
  • Calzepin
  • Camapine
  • Carazepin
  • Carbadac
  • Carbagen
  • Carbalex
  • Carbam
  • Carbamazepin-B
  • Carbapex
  • Carbapin
  • Carbastal
  • Carbatec
  • Carbatol
  • Carbatol CR
  • Carbazene
  • Carbazina
  • Carbilepp
  • Carmapine
  • Carmaz
  • Carmian
  • Carmine
  • Carpin
  • Carzep
  • Carzepin
  • Ceplep
  • Convulax
  • Degranol
  • Elpenor
  • Epazin
  • Epicarb
  • Epilep
  • Epilep CR
  • Epileptol
  • Epileptol CR
  • Eposal Retard
  • Espa-lepsin
  • Finlepsin
  • Fitzecalm
  • Hermolepsin
  • Karbamazepin
  • Lepsitol
  • Mezacar
  • Mezacar SR
  • Neugeron
  • Neurolep
  • Neurotol
  • Neurotop
  • Sirtal
  • Stazepine
  • Storilat
  • Taver
  • Tegol
  • Tegral
  • Tegretal
  • Tegretol
  • Tegretol CR
  • Tegretol Retard
  • Tegretol-XR
  • TegretolCR
  • Temporol
  • Teril
  • Teril-CR
  • Timonil
  • Timonil Retard
  • Torbarec
  • Trepina
  • Trimonil Retard
  • Vulsivan
  • Zeptol CR
  • Zigma CR

Carbamazepine Brands in Pakistan:

Carbamazepine [Syrup 100 mg/5ml]
CARZEP GLITZ PHARMA
ZEPTOL LIFE PHARMACEUTICAL COMPANY

 

Carbamazepine [Susp 100 mg/5ml]
CARBANIL DOSACO LABORATORIES
EPICAR ADAMJEE PHARMACEUTICALS (PVT) LTD.
EPILEPSIN MACTER INTERNATIONAL (PVT) LTD.
NEU-NIL LEAMA CHEMI PHARMA (PVT.) LTD.
SEIZUNIL PLATINUM PHARMACEUTICALS (PVT.) LTD.
TEGRAL NOVARTIS PHARMA (PAK) LTD

 

Carbamazepine [Tabs 200 mg]
ALCRABANE ALSON PHARMACEUTICALS
AZAPIN SILVER OAK CORPORATION.
CARBACID CANDID PHARMACEUTICALS
CARBANIL DOSACO LABORATORIES
CARBAPINE CSH PHARMACEUTICALS-NORTH (PVT) LTD
CARBAZINE S. EJAZUDDIN & COMPANY
CAZAP USAWA PHARMACEUTICALS
CONVUL SIZA INTERNATIONAL (PVT) LTD.
EPICAR ADAMJEE PHARMACEUTICALS (PVT) LTD.
EPIGRAL MEDICRAFT PHARMACEUTICALS (PVT) LTD.
EPILEPSIN MACTER INTERNATIONAL (PVT) LTD.
EPILEX BRYON PHARMACEUTICALS (PVT) LTD.
EPISIEZ MEDICAIDS PAKISTAN (PVT) LTD.
EPISOL STAR LABORATORIES (PVT) LTD.
EPITAB-XR WERRICK PHARMACEUTICALS
KARBATON MASS PHARMA (PRIVATE) LIMITED
LEPTIC BIO LABS (PVT) LTD.
LEXOPINE HIGHNOON LABORATORIES LTD.
MAZETOL CIBEX (PRIVATE) LIMITED
MEZAPINE VALOR PHARMACEUTICALS
MEZICARB MEDERA PHARMACEUTICALS (PVT) LTD.
MEZINE BLOOM PHARMACEUTICALS (PVT) LTD.
SADMIC ZEB LABORATORIES
SEIZUNIL PLATINUM PHARMACEUTICALS (PVT.) LTD.
TABTOL UMAIR ASSOCIATES
TEGRAL NOVARTIS PHARMA (PAK) LTD
TEGRAM MEDIATE PHARMACEUTICALS (PVT) LTD
TERIL MERCK PRIVATE LTD.
XEPIL Shaigan Pharmaceuticals (PVT) LTD

 

Carbamazepine [Tabs 400 mg]
CAZAP XR USAWA PHARMACEUTICALS
EPITAB-XR WERRICK PHARMACEUTICALS
SEIZUNIL PLATINUM PHARMACEUTICALS (PVT.) LTD.

 

Carbamazepine [Tabs SR 200 mg]
CONVUL SIZA INTERNATIONAL (PVT) LTD.

 

Carbamazepine [Caps SR 200 mg]
CARBASCOT SCOTMANN PHARMACEUTICALS

 

Carbamazepine [Caps SR 400 mg]
CARBASCOT SCOTMANN PHARMACEUTICALS
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