5ASA 5-aminosalicylates + azathioprine 5-aminosalicylates may increase bone marrow toxicity of azathioprine (may be less likely with balsalazide);

monitor complete blood picture more often when starting the combination. 5-aminosalicylates + mercaptopurine 5-aminosalicylates may increase bone marrow toxicity of mercaptopurine (may be less likely with balsalazide); monitor complete blood picture more often when starting the combination. sulfasalazine + digoxin Sulfasalazine may decrease digoxin concentration and its clinical effect; monitor digoxin concentration and clinically; increase digoxin dose if necessary. sulfasalazine + folic acid Sulfasalazine impairs absorption of folic acid; consider folic acid supplement, especially before and during pregnancy.

NSAID cannot be avoided use lowest effective dose for shortest period of time phenytoin + corticosteroids Phenytoin increases metabolism of dexamethasone, fludrocortisone, methylprednisolone, prednisolone and prednisone; may reduce their activity; monitor clinical effect and increase corticosteroid dose if necessary (large increases may be needed). Phenytoin's metabolism may be affected. As the dexamethasone suppression test may be inaccurate, alternative investigations may be necessary. rifampicin + corticosteroids Rifampicin increases metabolism of cortisone, fludrocortisone, hydrocortisone, methylprednisolone, prednisone and prednisolone, and may reduce their activity; monitor clinical effect and increase corticosteroid dose if needed (may need to double dose). corticosteroids + warfarin Corticosteroids may increase warfarin's anticoagulant effect, increasing the risk of bleeding; monitor INR and

CORTICOSTEROID
Systemic corticosteroids (especially cortisone, hydrocortisone and fludrocortisone) reduce potassium concentration and increase risk of hypokalaemia. Administration with other drugs* that also reduce potassium concentration may increase this risk; monitor potassium concentration and give supplements if necessary. The glucocorticoids can increase blood glucose concentration.Use of topical corticosteroids, eg inhaled or on the skin, is less likely to result in drug interactions than systemic use, but interactions may occur rarely, see Budesonide, Fluticasone, Triamcinolone. corticosteroids + aspirin Corticosteroids may decrease salicylate concentration when high-dose aspirin is used, eg in Kawasaki's disease; monitor salicylate concentration and clinical effect; increase aspirin dose if necessary; be particularly careful to reduce the aspirin dose when withdrawing the corticosteroid. corticosteroids + NSAIDs Oral corticosteroids increase risk of gastric ulceration with NSAIDs; consider need for an NSAID carefully; if an

decrease warfarin dose if necessary. Budesonide itraconazole + budesonide Itraconazole may inhibit metabolism of inhaled budesonide; Cushing's syndrome has occurred after giving itraconazole with inhaled budesonide; monitor clinically and consider reducing budesonide dose or using an alternative corticosteroid. This interaction is likely to occur with oral or intranasal budesonide. ketoconazole + budesonide Ketoconazole increases budesonide concentration when budesonide is given orally; minimise by giving doses 12 hours apart; monitor for adverse effects of budesonide and reduce dose if necessary. This interaction also occurs with inhaled budesonide and may occur if it is given intranasally; monitor clinically and consider reducing budesonide dose or using an alternative corticosteroid. ritonavir + budesonide Ritonavir increases budesonide concentration when budesonide is given by any route; this may result in Cushing's syndrome; avoid budesonide and use an alternative corticosteroid, eg beclomethasone. Dexamethasone aprepitant + dexamethasone

Aprepitant increases dexamethasone concentration, increasing risk of adverse effects. Check whether protocol already has the reduced oral dexamethasone dose in the antiemetic regimen. 3-day (fos)aprepitant course: halve oral dexamethasone dose. 1-day fosaprepitant course: halve oral dexamethasone dose only on days 1 and 2. carbamazepine + dexamethasone Carbamazepine increases dexamethasone metabolism; may reduce its activity; monitor clinical effect and increase dexamethasone dose if necessary. As the dexamethasone suppression test may be inaccurate alternative investigations may be necessary. caspofungin + dexamethasone itraconazole + dexamethasone Itraconazole reduces metabolism and enhances clinical effect of dexamethasone; no action required when dexamethasone is used short term; otherwise, monitor for dexamethasone adverse effects and reduce its dose if necessary. magnesium trisilicate + dexamethasone Magnesium trisilicate may decrease absorption of dexamethasone; separate administration by at least 2 hours to minimise this and monitor clinically; increase dexamethasone dose if necessary. phenobarbitone + dexamethasone Phenobarbitone increases dexamethasone's metabolism; may reduce its activity; monitor clinical effect and increase dexamethasone dose if necessary. As the dexamethasone suppression test may be inaccurate alternative investigations may be necessary. praziquantel + dexamethasone ritonavir + dexamethasone Ritonavir may increase dexamethasone concentration; Cushing's syndrome has occurred after ritonavir was given with long-term, high-dose dexamethasone eye drops; in similar circumstances, consider avoiding dexamethasone and using an alternative corticosteroid. This interaction is also likely to occur if dexamethasone is given by other routes. Fluticasone itraconazole + fluticasone Itraconazole may inhibit metabolism of fluticasone; Cushing's syndrome has occurred after giving itraconazole

with inhaled fluticasone; monitor clinically and consider reducing fluticasone dose or using an alternative corticosteroid. ritonavir + fluticasone Ritonavir may inhibit metabolism of fluticasone; Cushing's syndrome has occurred after giving ritonavir with inhaled or intranasal fluticasone; avoid combination and use an alternative corticosteroid, eg beclomethasone. Hydrocortisone bile acid binding resins + hydrocortisone Bile acid binding resins may bind hydrocortisone in the GIT and decrease its absorption; to minimise this, give hydrocortisone at least 1 hour before, or 46 hours after, resin and monitor its clinical effect; increase hydrocortisone dose if necessary. oxcarbazepine + hydrocortisone Oxcarbazepine increases metabolism of hydrocortisone, decreasing its concentration and its clinical effect. Use an alternative antiepileptic, eg levetiracetam, as increasing the hydrocortisone dose may not normalise biochemical results or eliminate clinical symptoms of adrenal insufficiency. Methylprednisolone aprepitant + methylprednisolone Aprepitant increases concentration of methylprednisolone, the extent depending on whether methylprednisolone is given IV or orally; decrease IV methylprednisolone dose given on day 1 of aprepitant treatment by one-quarter and halve the oral doses given on days 2 and 3 (check whether protocol already has the reduced dose). There are no data for the IV fosaprepitant 150 mg regimen. diltiazem + methylprednisolone Diltiazem reduces metabolism, increases concentration and clinical effect of methylprednisolone; no action required when methylprednisolone is used short term. itraconazole + methylprednisolone Itraconazole reduces metabolism and enhances clinical effect of methylprednisolone; no action required when methylprednisolone is used short term. ketoconazole + methylprednisolone Ketoconazole reduces metabolism and enhances clinical effect of methylprednisolone; no action required when methylprednisolone is used short term. phenobarbitone + methylprednisolone

Phenobarbitone increases methylprednisolone's metabolism; may reduce its activity; monitor clinical effect and increase methylprednisolone dose if necessary. Prednisolone, see Prednisone

Prednisone Prednisone is metabolised to the active metabolite prednisolone and vice versa, however, no matter which is given, prednisone is mostly converted to prednisolone before elimination. Thus drug interactions affecting one will also affect the other. phenobarbitone + prednisone Phenobarbitone increases prednisone's metabolism; may reduce its activity; monitor clinical effect and increase prednisone dose if necessary. ritonavir + prednisone Ritonavir may increase concentration of prednisone's active metabolite, prednisolone, increasing the risk of adverse effects; monitor clinically and reduce prednisone dose if necessary. Triamcinolone ritonavir + triamcinolone Ritonavir may inhibit the metabolism of triamcinolone; this has resulted in Cushing's syndrome after 1 or 2 doses of epidural, IM or intra-articular triamcinolone acetonide; this may also occur when triamcinolone is given by other routes, eg intranasally. Choose an alternative corticosteroid.