levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s). paroxetine will increase the level or effect of dextroamphetamine transdermal by affecting hepatic enzyme CYP2D6 metabolism. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor patients for signs and symptoms of serotonin syndrome, particularly during dextroamphetamine initiation and after a dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and CYP2D6 inhibitor.perphenazineMonitor Closely (1)perphenazine, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s).phenelzineContraindicated (1)phenelzine increases effects of dextroamphetamine transdermal by decreasing metabolism. Contraindicated. MAOIs slows amphetamine metabolism, increasing amphetamine?s effect on norepinephrine release and other monoamines from adrenergic nerve endings causing signs of hypertensive crisis. Do not administer dextroamphetamine during or within 14 days following MAOI administration.Monitor Closely (1)phenelzine, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s).potassium acid phosphateMonitor Closely (1)potassium acid phosphate will decrease the level or effect of dextroamphetamine transdermal by Other (see comment). Modify Therapy/Monitor Closely. Urinary acidifying agents can lower blood levels and efficacy of amphetamines. Increase dose of dextroamphetamine transdermal based on clinical response.potassium citrateSerious - Use Alternative (1)potassium citrate will increase the level or effect of dextroamphetamine transdermal by Other (see comment). Avoid or Use Alternate Drug. Urinary alkalinizing agents can increase blood levels and potentiate the action of amphetamine.potassium citrate/citric acidSerious - Use Alternative (1)potassium citrate/citric acid will increase the level or effect of dextroamphetamine transdermal by Other (see comment). Avoid or Use Alternate Drug. Urinary alkalinizing agents can increase blood levels and potentiate the action of amphetamine.procarbazineContraindicated (1)procarbazine increases effects of dextroamphetamine transdermal by decreasing metabolism. Contraindicated. MAOIs slows amphetamine metabolism, increasing amphetamine?s effect on norepinephrine release and other monoamines from adrenergic nerve endings causing signs of hypertensive crisis. Do not administer dextroamphetamine during or within 14 days following MAOI administration.protriptylineMonitor Closely (1)protriptyline will increase the level or effect of dextroamphetamine transdermal by pharmacodynamic synergism. Modify Therapy/Monitor Closely. May enhance the activity of tricyclic or sympathomimetic agents causing striking and sustained increases in dextroamphetamine levels in brain; May be potentiate cardiovascular effects. Monitor frequently and adjust or use an alternant based on clinical response.quinidineMonitor Closely (1)quinidine will increase the level or effect of dextroamphetamine transdermal by affecting hepatic enzyme CYP2D6 metabolism. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor patients for signs and symptoms of serotonin syndrome, particularly during dextroamphetamine initiation and after a dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and CYP2D6 inhibitor.rizatriptanMonitor Closely (1)rizatriptan, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s).rolapitantMonitor Closely (1)rolapitant will increase the level or effect of dextroamphetamine transdermal by affecting hepatic enzyme CYP2D6 metabolism. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor patients for signs and symptoms of serotonin syndrome, particularly during dextroamphetamine initiation and after a dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and CYP2D6 inhibitor.sertralineMonitor Closely (1)sertraline, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s).St John's WortMonitor Closely (1)St John's Wort, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s).sumatriptanMonitor Closely (1)sumatriptan, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s).terbinafineMonitor Closely (1)terbinafine will increase the level or effect of dextroamphetamine transdermal by affecting hepatic enzyme CYP2D6 metabolism. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor patients for signs and symptoms of serotonin syndrome, particularly during dextroamphetamine initiation and after a dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and CYP2D6 inhibitor.thioridazineMonitor Closely (1)thioridazine will increase the level or effect of dextroamphetamine transdermal by affecting hepatic enzyme CYP2D6 metabolism. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor patients for signs and symptoms of serotonin syndrome, particularly during dextroamphetamine initiation and after a dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and CYP2D6 inhibitor.tipranavirMonitor Closely (1)tipranavir will increase the level or effect of dextroamphetamine transdermal by affecting hepatic enzyme CYP2D6 metabolism. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor patients for signs and symptoms of serotonin syndrome, particularly during dextroamphetamine initiation and after a dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and CYP2D6 inhibitor.tramadolMonitor Closely (1)tramadol, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s).tranylcypromineContraindicated (1)tranylcypromine increases effects of dextroamphetamine transdermal by decreasing metabolism. Contraindicated. MAOIs slows amphetamine metabolism, increasing amphetamine?s effect on norepinephrine release and other monoamines from adrenergic nerve endings causing signs of hypertensive crisis. Do not administer dextroamphetamine during or within 14 days following MAOI administration.Monitor Closely (1)tranylcypromine, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s).trazodoneMonitor Closely (1)trazodone, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s).trimipramineMonitor Closely (1)trimipramine will increase the level or effect of dextroamphetamine transdermal by pharmacodynamic synergism. Modify Therapy/Monitor Closely. May enhance the activity of tricyclic or sympathomimetic agents causing striking and sustained increases in dextroamphetamine levels in brain; May be potentiate cardiovascular effects. Monitor frequently and adjust or use an alternant based on clinical response.venlafaxineMonitor Closely (1)venlafaxine, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s).vilazodoneMonitor Closely (1)vilazodone, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s).ziprasidoneMonitor Closely (1)ziprasidone, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s).zolmitriptanMonitor Closely (1)zolmitriptan, dextroamphetamine transdermal. Either increases effects of the other by serotonin levels. Modify Therapy/Monitor Closely. Initiate with lower doses and monitor for signs and symptoms of serotonin syndrome, particularly during initiation or dosage increase. If serotonin syndrome occurs, discontinue dextroamphetamine transdermal and concomitant serotonergic drug(s). >10% Decreased neutrophils (14%) Decreased appetite (12%) 1-10% Decreased WBCs in pediatric patients (10%) Insomnia (8%) Application site reactions, discomfort (8%) Headache (6%) Vomiting (4%) Abdominal pain (4%) Nausea (3%) Affect liability (3%) Tic (2%) Irritability (2%) Blood pressure increased (2%) Heart rate increased (2%) Postmarketing Reports (for amphetamines) Cardiac disorders: Palpitations, chest pain, sudden death, myocardial infarction, and cardiomyopathy (isolated reports) Eye disorders: Vision blurred, diplopia, difficulties with visual accommodation, and mydriasis Gastrointestinal disorders: Dysgeusia, constipation, intestinal ischemia, and other gastrointestinal disturbances Hepatobiliary disorders: Eosinophilic hepatitis Immune system disorders: Urticaria, rash, hypersensitivity reactions including angioedema and anaphylactic reactions, and serious skin rashes, including Stevens-Johnson syndrome and toxic epidermal necrolysis Musculoskeletal and connective tissue disorders: Rhabdomyolysis Nervous system disorders: Seizures, overstimulation, restlessness, dyskinesia, tremor, tics, and paresthesia (including formication) Psychiatric disorders: Psychotic episodes at recommended doses, depression, logorrhea, aggression, anger, dermatillomania, bruxism, dysphoria, euphoria, and irritability Reproductive system and breast disorders: Impotence, changes in libido, and frequent or prolonged erections Skin and subcutaneous tissue disorders: Alopecia Vascular disorders: Raynaud phenomenon Black Box Warnings Abuse and dependence CNS stimulants, including dextroamphetamine transdermal, other amphetamine-containing products, and methylphenidate, have high potential for abuse and dependence Assess risk of abuse before prescribing and monitor for signs of abuse and dependence during treatment Contraindications Hypersensitivity to amphetamine products or other components of transdermal system; anaphylactic reactions, Stevens-Johnson syndrome, angioedema, and urticaria have been observed in postmarketing reports During or within 14 days following MAOI administration (hypertensive crises may result) Cautions Has high potential for abuse and dependence CNS stimulants may increase BP and HR; monitor for potential tachycardia and hypertension Stimulants are associated with peripheral vasculopathy, including Raynaud phenomenon; signs and symptoms usually improve after reducing the dose or discontinuing therapy; careful observation for digital changes is necessary during treatment; further clinical evaluation (eg, rheumatology referral) may be appropriate for certain patients Advise patients to avoid exposing transdermal system to direct external heat sources (eg, hair dryers, heating pads, electric blankets, heated water beds); heat may increase rate and extent of absorption Serious cardiovascular reactions Sudden death, stroke, hypertension, and myocardial infarction reported in adults with CNS stimulants Serious cardiovascular reactions have occurred at recommended doses Sudden death reported in pediatric patients with structural cardiac abnormalities or other serious heart problems taking CNS stimulants Avoid use in patients with known structural cardiac abnormalities, cardiomyopathy, serious heart arrhythmia, coronary artery disease, and other serious heart problems Further evaluate patients who develop exertional chest pain, unexplained syncope, or arrhythmias during treatment Psychiatric adverse reactions CNS stimulants may exacerbate symptoms of behavior disturbance and thought disorder in patients with pre-existing psychotic disorder CNS stimulants may induce mixed/manic episode in patients with bipolar disorder Before initiating, screen for risk factors for developing a manic episode (eg, comorbid or history of depressive symptoms, family history of suicide, bipolar disorder, depression) CNS stimulants, at recommended doses, may cause psychotic or manic symptoms (eg, hallucinations, delusional thinking, or mania) in patients without prior history of psychotic illness or mania If these symptoms occur, consider discontinuing treatment Growth suppression CNS stimulants associated with weight loss and slowing of growth rate in pediatric patients Closely monitor growth (weight and height) in pediatric patients treated with CNS stimulants Consider interrupting treatment in patients who are not growing or gaining height or weight as expected Not approved for use in children aged <6 years Application site reactions Local skin reactions (eg, pain, pruritus, burning sensation, erythema, discomfort, edema, swelling) have been reported Inform patients that increased skin irritation, discomfort or pain may occur if the same application site is used repeatedly Instruct patients to select a different application site each day to minimize skin reactions Monitor for these reactions while wearing or immediately after removal; symptoms reported to resolve 2-4 hr after application Discontinue treatment if contact sensitization is suspected Serotonin syndrome Coadministration with other drugs that affect the serotonergic neurotransmitter systems such as monoamine oxidase inhibitors (MAOIs), selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, triptans, tricyclic antidepressants (TCAs), fentanyl, lithium, tramadol, tryptophan, buspirone, and St. John Wort may cause serotonin syndrome Coadministration with CYP2D6 inhibitors may also increase risk by increasing exposure to dextroamphetamine If this situation arises, consider use of an alternative non-serotonergic drug or an alternative drug that does not inhibit CYP2D6 Serotonin syndrome symptoms may include mental status changes (eg, agitation, hallucinations, delirium, and coma), autonomic instability (eg, tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (eg,