CYP1A2 metabolism. Use Caution/Monitor. Limited published data indicate that growth hormone treatment increases cytochrome P450 (CYP450)-mediated antipyrine clearance. Caution with sensitive CYP substratessotalolSerious - Use Alternative (1)fluvoxamine and sotalol both increase QTc interval. Avoid or Use Alternate Drug.sparsentanMonitor Closely (1)fluvoxamine will increase the level or effect of sparsentan by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. No dosage adjustment needed. Monitor blood pressure, serum potassium, edema, and kidney function regularly if sparsentan is coadministered with moderate CYP3A4 inhibitors. St John's WortSerious - Use Alternative (1)fluvoxamine and St John's Wort both increase serotonin levels. Avoid or Use Alternate Drug.stiripentolMonitor Closely (1)fluvoxamine, stiripentol. affecting hepatic enzyme CYP1A2 metabolism. Modify Therapy/Monitor Closely. May require dosage adjustment.sufentanilMonitor Closely (1)fluvoxamine and sufentanil both increase serotonin levels. Use Caution/Monitor. Carefully observe patient for serotonin syndrome during treatment initiation and dose adjustmentsufentanil SLMonitor Closely (1)fluvoxamine and sufentanil SL both decrease serotonin levels. Use Caution/Monitor. Carefully observe patient for serotonin syndrome during treatment initiation and dose adjustmentsulfamethoxazoleMonitor Closely (1)fluvoxamine and sulfamethoxazole both increase QTc interval. Use Caution/Monitor.sulfasalazineMonitor Closely (1)fluvoxamine will increase the level or effect of sulfasalazine by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of upper GI bleeding SSRIs inhib. serotonin uptake by plateletssulindacMonitor Closely (1)fluvoxamine, sulindac. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor.sumatriptanMonitor Closely (1)fluvoxamine and sumatriptan both increase serotonin levels. Modify Therapy/Monitor Closely.sumatriptan intranasalMonitor Closely (1)fluvoxamine and sumatriptan intranasal both increase serotonin levels. Modify Therapy/Monitor Closely.sunitinibMonitor Closely (2)sunitinib and fluvoxamine both increase QTc interval. Use Caution/Monitor. fluvoxamine will increase the level or effect of sunitinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.tacrolimusMonitor Closely (2)fluvoxamine will increase the level or effect of tacrolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. tacrolimus and fluvoxamine both increase QTc interval. Use Caution/Monitor.tadalafilMonitor Closely (1)fluvoxamine will increase the level or effect of tadalafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.tamoxifenMonitor Closely (1)fluvoxamine, tamoxifen. affecting hepatic enzyme CYP2C9/10 metabolism. Use Caution/Monitor. Decreases tamoxifen metabolism to active metabolites.tapentadolMonitor Closely (1)fluvoxamine and tapentadol both increase serotonin levels. Modify Therapy/Monitor Closely.tasimelteonMonitor Closely (1)fluvoxamine will increase the level or effect of tasimelteon by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. May increase adverse effectstazemetostatSerious - Use Alternative (1)fluvoxamine will increase the level or effect of tazemetostat by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Avoid or Use Alternate Drug. Avoid coadministration of avapritinib with moderate CYP3A4 inhibitors. If unable to avoid, reduce avapritinib starting dose. See drug monograph Dosage ModificationstedizolidSerious - Use Alternative (1)fluvoxamine and tedizolid both increase serotonin levels. Avoid or Use Alternate Drug.telavancinMonitor Closely (1)fluvoxamine and telavancin both increase QTc interval. Use Caution/Monitor.temsirolimusMonitor Closely (1)fluvoxamine will increase the level or effect of temsirolimus by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.terbinafineMonitor Closely (2)fluvoxamine will increase the level or effect of terbinafine by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor. terbinafine will increase the level or effect of fluvoxamine by affecting hepatic enzyme CYP2D6 metabolism. Modify Therapy/Monitor Closely. Assess need to reduce dose of CYP2D6-metabolized drug.teriflunomideMonitor Closely (1)teriflunomide will decrease the level or effect of fluvoxamine by affecting hepatic enzyme CYP1A2 metabolism. Use Caution/Monitor.tetrabenazineSerious - Use Alternative (1)tetrabenazine and fluvoxamine both increase QTc interval. Avoid or Use Alternate Drug.tezacaftorMonitor Closely (1)fluvoxamine will increase the level or effect of tezacaftor by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Adjust dose when coadministered with a moderate CYP3A4 inhibitortheophyllineSerious - Use Alternative (1)fluvoxamine will increase the level or effect of theophylline by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.thioridazineSerious - Use Alternative (2)fluvoxamine will increase the level or effect of thioridazine by affecting hepatic enzyme CYP1A2 metabolism. Contraindicated. fluvoxamine and thioridazine both increase QTc interval. Contraindicated.tinidazoleMonitor Closely (1)fluvoxamine will increase the level or effect of tinidazole by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.tipranavirMonitor Closely (1)fluvoxamine will increase the level or effect of tipranavir by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.Serious - Use Alternative (1)tipranavir will increase the level or effect of fluvoxamine by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.tizanidineSerious - Use Alternative (1)fluvoxamine will increase the level or effect of tizanidine by affecting hepatic enzyme CYP1A2 metabolism. Avoid or Use Alternate Drug.tofacitinibMonitor Closely (1)fluvoxamine increases levels of tofacitinib by affecting hepatic enzyme CYP2C19 metabolism. Use Caution/Monitor. Decrease tofacitinib dose is coadministered with both moderate CYP3A4 and potent CYP2C19 inhibitors.tolbutamideMonitor Closely (1)fluvoxamine will increase the level or effect of tolbutamide by affecting hepatic enzyme CYP2C9/10 metabolism. Use Caution/Monitor.tolfenamic acidMonitor Closely (1)fluvoxamine, tolfenamic acid. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of upper GI bleeding. SSRIs inhib. serotonin uptake by platelets.tolmetinMonitor Closely (1)fluvoxamine, tolmetin. Either increases toxicity of the other by pharmacodynamic synergism. Use Caution/Monitor. Increased risk of upper GI bleeding. SSRIs inhib. serotonin uptake by platelets.tolvaptanSerious - Use Alternative (1)fluvoxamine will increase the level or effect of tolvaptan by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Contraindicated.tramadolMonitor Closely (1)fluvoxamine and tramadol both increase serotonin levels. Modify Therapy/Monitor Closely.tranylcypromineSerious - Use Alternative (1)fluvoxamine and tranylcypromine both increase serotonin levels. Contraindicated.trazodoneMonitor Closely (1)fluvoxamine and trazodone both increase QTc interval. Modify Therapy/Monitor Closely.Serious - Use Alternative (1)fluvoxamine and trazodone both increase serotonin levels. Avoid or Use Alternate Drug.triazolamMonitor Closely (1)fluvoxamine will increase the level or effect of triazolam by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.trifluoperazineMonitor Closely (1)fluvoxamine and trifluoperazine both increase QTc interval. Modify Therapy/Monitor Closely.trimethoprimMonitor Closely (1)fluvoxamine and trimethoprim both increase QTc interval. Use Caution/Monitor.trimipramineMonitor Closely (1)fluvoxamine and trimipramine both increase QTc interval. Modify Therapy/Monitor Closely.Serious - Use Alternative (1)fluvoxamine will increase the level or effect of trimipramine by affecting hepatic enzyme CYP2D6 metabolism. Avoid or Use Alternate Drug.tropisetronMonitor Closely (1)fluvoxamine and tropisetron both increase QTc interval. Use Caution/Monitor.valbenazineMonitor Closely (1)valbenazine and fluvoxamine both increase QTc interval. Use Caution/Monitor.valerianMonitor Closely (1)fluvoxamine and valerian both increase sedation. Use Caution/Monitor.vardenafilMonitor Closely (1)fluvoxamine will increase the level or effect of vardenafil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Vardenafil dose may need to be reduced if coadministered with moderate or strong CYP3A4 inhibitors velpatasvirMonitor Closely (1)fluvoxamine will increase the level or effect of velpatasvir by affecting hepatic enzyme CYP2B6 metabolism. Use Caution/Monitor.venlafaxineMonitor Closely (1)fluvoxamine and venlafaxine both increase QTc interval. Use Caution/Monitor.Serious - Use Alternative (1)fluvoxamine and venlafaxine both increase serotonin levels. Avoid or Use Alternate Drug.verapamilMonitor Closely (1)fluvoxamine will increase the level or effect of verapamil by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.vilazodoneSerious - Use Alternative (1)fluvoxamine and vilazodone both increase serotonin levels. Avoid or Use Alternate Drug. Discontinue concomitant therapy immediately if signs and symptoms of serotonin syndrome emerge and supportive sympathomimetic treatment should be initiatedvoclosporinMonitor Closely (1)fluvoxamine will increase the level or effect of voclosporin by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Reduce voclosporin daily dosage to 15.8 mg PO in AM and 7.9 mg PO in PM.vorapaxarMonitor Closely (1)fluvoxamine, vorapaxar. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. SSRIs and SNRIs may cause platelet serotonin depletion.voriconazoleMonitor Closely (1)fluvoxamine and voriconazole both increase QTc interval. Use Caution/Monitor.vorinostatMonitor Closely (1)vorinostat and fluvoxamine both increase QTc interval. Use Caution/Monitor.vortioxetineSerious - Use Alternative (1)fluvoxamine, vortioxetine. Either increases effects of the other by serotonin levels. Avoid or Use Alternate Drug.warfarinMonitor Closely (1)fluvoxamine, warfarin. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Serotonin release by platelets plays an important role in hemostasis. SSRIs and SNRIs may increase anticoagulation effect of warfarin. .zaleplonMonitor Closely (1)fluvoxamine will increase the level or effect of zaleplon by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.zanubrutinibMonitor Closely (1)fluvoxamine will increase the level or effect of zanubrutinib by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Modify Therapy/Monitor Closely. Reduce zanubrutinib (a CYP3A4 substrate) to 80 mg PO BID to when coadministered with a moderate CYP3A4 inhibitor. Interrupt dose as recommended for adverse reactions. After discontinuing the CYP3A4 inhibitor, resume previous dose of zanubrutinib. ziprasidoneMonitor Closely (1)fluvoxamine and ziprasidone both increase QTc interval. Modify Therapy/Monitor Closely.zolmitriptanMonitor Closely (1)fluvoxamine and zolmitriptan both increase serotonin levels. Modify Therapy/Monitor Closely.zolpidemMonitor Closely (1)fluvoxamine will increase the level or effect of zolpidem by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor.zonisamideMonitor Closely (1)fluvoxamine will increase the level or effect of zonisamide by affecting hepatic/intestinal enzyme CYP3A4 metabolism. Use Caution/Monitor. >10% Nausea (40%) Headache (22-35%) Somnolence (22-27%) Weakness (14-26%) Insomnia (20-35%) Diarrhea (11-18%) Dizziness (11-15%) Xerostomia (10-14%) Anorexia (6-14%) Abnormal ejaculation (8-11%) 1-10% Pain (10%) Dyspepsia (8-10%) Constipation (4-10%) Decreased libido (2-10%) Upper respiratory infections (9%) Anxiety (5-8%) Tremor (5-8%) Sweating (6-7%) Vomiting (4-6%) Abdominal pain (5%) Myalgia (5%) Abnormal taste (2-5%) Bruising (4%) Abnormal dreams (3%) Abnormal thinking (3%) Chest pain (3%) Palpitation (3%) Agitation (2-3%) Vasodilation (2-3%) Hypertension (1-2%) Increased LFTs (1-2%) Weight change (1-2%) Manic reaction <1% Activation of mania/hypomania, seizures (discontinue) Sinusitis Frequency Not Defined Edema Amnesia Apathy Asthenia Malaise Nervousness Dry mouth Myoclonus Cough Black Box Warnings In short-term studies, antidepressants increased the risk of suicidal thinking and behavior in children, adolescents, and young adults (<24 years) taking antidepressants for major depressive disorders and other psychiatric illnesses This increase was not seen in patients aged >24 years; a slight decrease in suicidal thinking was seen in adults >65 years In children and young adults, risks must be weighed against the benefits of taking antidepressants Patients should be monitored closely for changes in behavior, clinical worsening, and suicidal tendencies; this should be done during initial 1-2 months of therapy and dosage adjustments The patient’s family should communicate any abrupt changes in behavior to the healthcare provider Worsening behavior and suicidal tendencies that are not part of the presenting symptoms may require discontinuation of therapy This drug is not approved for use in pediatric patientsContraindications Hypersensitivity Coadministration with serotonergic drugs Concomitant use or within 14 days of MAOIs increases risk of serotonin syndrome Reactions to concomitant administration with MAOIs include tremor, myoclonus, diaphoresis, nausea, vomiting, flushing, dizziness, hyperthermia with features resembling neuroleptic malignant syndrome, seizures, rigidity, autonomic instability with possible rapid fluctuations of vital signs, and mental status changes (including extreme agitation progressing to delirium and coma) Starting fluvoxamine in a patient who is being treated with linezolid or IV methylene blue is contraindicated because of an increased risk of serotonin syndrome If linezolid or IV methylene blue must be administered, discontinue SSRI immediately and monitor for CNS toxicity; may resume 24 hr after last linezolid or methylene blue dose, or after 2 weeks of monitoring (5 weeks for fluoxetine), whichever comes first Cautions Conflicting evidence regarding use of SSRIs during pregnancy and increased risk of persistent pulmonary hypertension of the newborn (see Pregnancy) In neonates exposed to SNRIs/SSRIs late in third trimester: Risk of complications such as feeding difficulties, irritability, and respiratory problems Risk of mydriasis; may trigger angle closure attack in patients with angle closure glaucoma with anatomically narrow angles without a patent iridectomy May need to modify dose for hepatic impairment; titrate at smaller increments and longer intervals Clinical worsening and suicide ideation may occur despite medication in adolescents and young adults (18-24 years); prescriptions should be written for the smallest quantity consistent with good patient care May worsen mania symptoms or precipitate mania in patients with bipolar disorder May impair platelet aggregation; increases risk of bleeding in patients taking anticoagulants/antiplatelets concomitantly Do not use concurrently with alosetron, astemizole, cisapride, pimozide, terfenadine, or tizanidine due to QT prolongation risk Potentially life-threatening serotonin syndrome has been reported with drugs that impair serotonin metabolism (in particular, MAOIs, including nonpsychiatric MAOIs, such as linezolid and IV methylene blue); it has also been reported with reported with SNRIs and SSRIs, including fluvoxamine, alone but particularly with concomitant use of serotonergic drugs (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. John's Wort (see Contraindications) May impair ability to operate heavy machinery and other tasks requiring mental alertness Bone fractures have been associated with antidepressant treatment; consider possibility of fragility fracture if patient presents with pain, joint tenderness, or swelling Impaired glucose control (hyperglycemia or hypoglycemia) reported; monitor for signs/symptoms of loss of glucose control, especially in patients with diabetes Syndrome of inapropriate antidiuretic hormone and hyponatremia reported with SSRI and SNRI use; volume deplretion and/or concurrent use of diuretics may increase risk; consider discontinuing therapy if symptomatic hyponatremia occurs Use caution in patients with cardiovascular disease or history of seizure disorder Sexual dysfunction Use of may cause symptoms of sexual dysfunction in both male and female patients; inform patients that they should discuss any changes in sexual function and potential management strategies with their healthcare