Managing menopausal symptoms and depression in tamoxifen users Implications of drug and medicinal interactions

Objective Tamoxifen a medication used in the treatment of breast cancer often induces menopausal symptoms Certain medications and natural supplements taken or prescribed to alleviate tamoxifen-induced hot flashes and depressive states in women with breast cancer Interact with tamoxifen This paper reviews potentially problematic interactions and offers treatment recommendations Methods Medline (1950-June 1 2010) Embase Classic + Embase (1947-June 1 2010) and PsycINFO (1967-June 1 2010) were searched through Ovid The word tamoxifen was searched with depression and then with menopaus* and symptoms with treatment as a limit Tamoxifen was later searched with the MeSH terms drug interaction or drug incompatibility Results Venlafaxine is efficacious for the treatment of hot flashes and depression and safe to use in combination with tamoxifen Gabapentin is also efficacious in treating tamoxifen-induced hot flashes and since it does not interact with cytochrome P450 system is likely safe to use in patients using tamoxifen Desvenlafaxine and pregabalm may be alternatives to venlafaxine and gabapentin respectively although desvenlafaxine has not yet been studied in this population Paroxetine fluoxetine and bupropion are strong CYP2D6 inhibitors which should be avoided in tamoxifen users Fluvoxamine and nefazodone both inhibit CYP3A which could potentially affect the metabolism of tamoxifen Clonidine can be an alternative agent but may carry significant side effects Evidence of medicinal products for the treatment of tamoxifen-induced hot flashes is equivocal at best Conclusions Clinicians should remain cautious about using strong inhibitors and/or inducers of cytochrome 2D6 and 3A4 concomitantly with tamoxifen Use of natural menopausal supplements and diets rich in isoflavones should not be encouraged in tamoxifen users until more data is available There are however safe treatments for hot flashes and depression in tamoxifen users (C) 2010 Elsevier Ireland Ltd All rights reserved