Potential Dangers of Co-prescribing Amitriptyline, Paroxetine and Ivabradine

Cegedim Healthcare Solutions have been made aware of an incident in relation to the sudden cardiac death of a patient as a result of Amitriptyline toxicity likely caused by an interaction between Amitriptyline, Paroxetine and Ivabradine that were co-administered to the patient. The combination of this trio of drugs did not trigger an alert on the prescribing software used in primary care or by pharmacists.

A Regulation 28 report has been issued by the Coroner for Hampshire, Portsmouth and Southampton to the National Institute for Health and Care Excellence (NICE) and the British National Formulary (BNF), as well as the Royal College of Physicians, calling upon them to take action to try and prevent future deaths.

GP practices are advised to be vigilant and cautious when co-prescribing this trio of drugs in view of the potential dangers and risk of interaction. In particular, that Ivabradine requires caution / monitoring when there are cardiac problems, and the combination of Amitriptyline and Paroxetine increases the risk of cardiac problems as a side effect. A reminder that, when reviewing patient medication, it is important to check for the appearance of any new side effects since medication was last prescribed as changes to a patient’s symptoms or functions (e.g. renal, hepatic, etc) may have arisen over time.

Interactions exist between pairs of drugs. Alerts are triggered and displayed for the various possible combinations of drug pairings when this combination is prescribed in Vision or dispensed using Pharmacy Manager.

An audit has been made available in Vision+ for use to identify patients co-prescribed these drugs. The name of the pathway is ‘Ivabradine Interaction Safety’ and the reporting lines are as follows:

This audit will be helpful where a practice may wish to undertake a review of patients co-prescribed these drugs.