Butalbital/aspirin/caffeine/codeine

Increased risk of hypotension, respiratory depression, sedation with benzodiazepines or other CNS depressants (eg, non-benzodiazepine sedatives/hypnotics, anxiolytics, general anesthetics, phenothiazines, tranquilizers, muscle relaxants, antipsychotics, alcohol, other opioids); reserve concomitant use in those for whom alternative options are inadequate; limit dosages/durations to minimum required; monitor closely; consider prescribing naloxone if concomitant use is warranted.  Increased risk of bleeding with chronic, heavy alcohol use (≥3 drinks/day). Risk of serotonin syndrome with serotonergic drugs (eg, SSRIs, SNRIs, TCAs, triptans, 5-HT₃ antagonists, mirtazapine, trazodone, tramadol, cyclobenzaprine, metaxalone, MAOIs, linezolid, IV methylene blue); monitor and discontinue if suspected. Avoid concomitant mixed agonist/antagonist opioids (eg, butorphanol, nalbuphine, pentazocine) or partial agonist (eg, buprenorphine); may reduce effects and/or precipitate withdrawal symptoms. Potentiated by CYP3A4 inhibitors (eg, macrolides, azole antifungals, protease inhibitors); if concomitant use is necessary, consider reducing dose of Butalbital/Aspirin/Caffeine/Codeine; monitor for respiratory depression and sedation. Antagonized by CYP3A4 inducers (eg, rifampin, carbamazepine, phenytoin); if concomitant use is necessary, consider increasing dose of Butalbital/Aspirin/Caffeine/Codeine; monitor for respiratory depression and sedation. May be affected by CYP2D6 inhibitors (eg, amiodarone, quinidine, fluoxetine, paroxetine, bupropion); if concomitant use is necessary, consider adjusting dose and monitor closely.  May antagonize diuretics; monitor. Paralytic ileus may occur with anticholinergics; monitor. May potentiate effects of anticoagulants (eg, warfarin, heparin, enoxaparin, clopidogrel, prasugrel, rivaroxaban, apixaban); monitor. Avoid concomitant uricosurics (eg, probenecid), corticosteroids. May potentiate carbonic anhydrase inhibitors (eg, acetazolamide, methazolamide); consider reducing dose of these. Concomitant methotrexate: monitor for toxicity esp. in elderly or renal impairment. Monitor renal function closely with concomitant nephrotoxic agents. May antagonize ACEIs, beta-blockers; monitor BP and renal function. May potentiate hypoglycemic agents (eg, insulin, glimepiride, glipizide). Increased risk of bleeding or lead to decreased renal function with concomitant NSAIDs; avoid. Caution with phenytoin, valproic acid. Codeine may increase serum amylase levels. May interfere with lab tests in blood or urine (eg, serum amylase, fasting blood glucose, cholesterol, protein, SGOT, uric acid, prothrombin time, bleeding time, glucose, 5- hydroxyindoleacetic acid, Gerhardt ketone, VMA, uric acid, diacetic acid, and spectrophotometric detection of barbiturates).