Josamycin and Midazolam Nasal Spray: Interaction Details
AI-assisted, pharmacist-reviewed · Source data updated Aug 8, 2026 · Sources: FDA labeling, DDInter 2.0, cited literature
Midazolam Nasal Spray
Josamycin
No brand names on record
How we grade severity & evidence
Severity levels
- Contraindicated: These should generally not be used together.
- Major: Potentially serious — often needs a change or close monitoring.
- Moderate: Can be significant — usually manageable with monitoring.
- Minor: Usually limited clinical impact.
Evidence grades
- Established: Well documented — supported by controlled studies or strong clinical data.
- Probable: Good supporting evidence, though not definitively proven.
- Suspected: Some evidence suggests this interaction, but it is not well established.
- Possible: Limited or conflicting evidence; the interaction may occur.
- Theoretical: Predicted from the drugs' pharmacology; not yet confirmed in people.
Ratings come from the documented interaction literature and are reviewed by a pharmacist. They describe the documented risk of the combination, not what will necessarily happen to you — your dose, timing, and health picture all matter.
What happens
Increased benzodiazepine toxicity (CNS depression, ataxia, lethargy)
Interaction Deep Dive
Macrolide antibiotics may inhibit hepatic enzymes responsible for benzodiazepine metabolism leading to increased plasma concentrations of benzodiazepines through reduced clearance, prolonged half-life, and increased volume of distribution4231.
Why it happens (mechanism)
Decreased hepatic metabolism; decreased clearance
Literature reports
3 reports — tap to read
a) An 8-year-old boy undergoing adenoidectomy was premedicated with oral midazolam 0.5 mg/kg and oral atropine 0.03 mg/kg, followed in one hour by intravenous erythromycin 400 mg. The patient lost consciousness 40 minutes later after 200 mg had been infused; other vital signs remained normal, and he regained consciousness after 45 minutes. At 170 minutes post-medication, his midazolam plasma concentration was 134 ng/mL. Six other children who were similarly premedicated (midazolam 0.5 mg/kg and atropine 0.03 mg/kg) but did not receive erythromycin had a mean midazolam level of 73 mg/mL 1.
b) In a study involving normal volunteers, erythromycin (333 mg three times daily for three days) increased the peak levels of triazolam by 50%, increased the half-life from four to six hours, and decreased the volume of distribution 2.
c) A double-blind, placebo-controlled study of healthy volunteers has found that clearance of intravenously administered midazolam is reduced by about 50% following five days of erythromycin therapy versus placebo 3.
Common questions
Can I take Josamycin and Midazolam Nasal Spray together?
Increased benzodiazepine toxicity (CNS depression, ataxia, lethargy) Always confirm with your pharmacist or prescriber before making any change.
How serious is the Josamycin and Midazolam Nasal Spray interaction?
It is rated moderate. Can be significant — usually manageable with monitoring.
How quickly could this interaction happen?
The documented onset is "delayed". Effects tend to build up gradually over days to weeks.
How strong is the evidence for this interaction?
The evidence is graded "theoretical". Predicted from the drugs' pharmacology; not yet confirmed in people.
Questions for your pharmacist
- Does my dose of Josamycin or Midazolam Nasal Spray need adjusting while I take them together?
- What symptoms should prompt me to call you or my prescriber right away?
- Does the timing of my doses matter for this combination?
- Is there anything you'd monitor while I'm on both?
References (4)
- Hiller A, Olkkola KT, Isohanni P, et al: Unconsciousness associated with midazolam and erythromycin. Br J Anaesth 1990; 65:826-828. PubMed
- Phillips JP, Antal EJ, & Smith RB: A pharmacokinetic drug interaction between erythromycin and triazolam. J Clin Psychopharmacol 1986; 6:297-299. DOI
- Olkkola KT, Aranko K, Luurila H, et al: A potentially hazardous interaction between erythromycin and midazolam. Clin Pharmacol Ther 1993; 53:298-305. PubMed
- Warot D, Bergougnan L, Lamiable D, et al: Troleandomycin-triazolam interaction in healthy volunteers: pharmacokinetic and psychometric evaluation. Eur J Clin Pharmacol 1987; 32:389-393. DOI
Keep reading about Midazolam Nasal Spray
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