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Examples of drugs known to be safe or unsafe in the acute porphyrias

Examples of drugs known to be safe or unsafe in the acute porphyrias
Safe

Acetaminophen (paracetamol)

Aminoglycosides

Anesthetic (eg, propofol)

Antiemetics* (ondansetron); refer to note

Aspirin

Atropine

Benzodiazepines (eg, lorazepam, midazolam); refer to note

Cephalosporins; refer to note

ErythropoietinΔ

Gabapentin

Glucocorticoids

Histamine2 receptor antagonistsΔ (eg, cimetidine, famotidine)

Insulin

Levetiracetam

Local anesthetics (eg, lidocaine, bupivacaine)

Opioid analgesics

Penicillin and derivatives

Phenothiazines (eg, chlorpromazine, prochlorperazine, promethazine)

Proton pump inhibitors (eg, lansoprazole, omeprazole, pantoprazole)

Vigabatrin
Unsafe

Alcohol

Anesthetics (eg, etomidate, ketamine, thiopental)

Antipyrine (phenazone)

BarbituratesΔ

CarbamazepineΔ

CarisoprodolΔ

Clonazepam (high doses)

DanazolΔ

DiclofenacΔ and possibly other NSAIDs

Efavirenz

Ergot derivatives (including dihydroergotamine)

EstrogensΔ

Ethosuximide and methsuximide

GriseofulvinΔ

Hydralazine

Hydroxyzine

MeprobamateΔ

Nifedipine

Nitrofurantoin

Oxcarbazepine

Pentazocine

PhenytoinΔ

PhenobarbitalΔ

PrimidoneΔ

Progesterone and synthetic progestinsΔ

PyrazinamideΔ

RifampinΔ

Spironolactone

Sulfasalazine

Sulfonamide antibioticsΔ (including trimethoprim-sulfamethoxazole [cotrimoxazole])

Tamoxifen

Topiramate

Valproic acidΔ
This table includes examples of commonly used drugs known to be safe or unsafe in the acute porphyrias (ie, porphyrias associated with acute neurovisceral attacks).
NOTE: This list is incomplete and includes drugs for which there is general agreement among experts. It is recommended that clinicians consult the websites of the American Porphyria Foundation and the European Porphyria Network, which are frequently updated; list many other drugs, including those that are not classified with certainty; and provide evidence for these classifications. Because the evidence base is inadequate, expert assessments of the safety of drugs in porphyria may differ. Refer to the UpToDate topics on individual porphyrias for more information.
NSAIDs: nonsteroidal antiinflammatory drugs.
* Serotonin 5HT3 antagonists are probably safe. Classification of metoclopramide is controversial but is generally a less effective antiemetic.
¶ Not all agents within the same class will necessarily have the same risk. For example, though opioids are generally considered safe, pentazocine may be unsafe. Benzodiazepines that are rapidly metabolized or administered in low doses are considered safe, but the safety of high doses or prolonged use of long-acting agents is less certain. There are conflicting reports on the safety of cephalosporins.
Δ In United States labeling for these drugs, porphyria is listed as a contraindication, warning, precaution, or adverse effect. Erythropoietin is regarded as safe by other sources. Estrogens are unsafe for porphyria cutanea tarda but can be used with caution in the acute porphyrias, especially in low doses or by the transdermal route.
Adapted from: Anderson KE, Bloomer JR, Bonkovsky HL, et al. Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med 2005; 142:439.
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