Drug-Herb Interactions Lecture 6 PDF

Lecture 6 Drug interactions PO 501 Dr. Naglaa El-Orabi  Drug interaction Drug interaction Drug-Herb Interactions The use of herbal medicati...

Lecture 6 Drug interactions PO 501 Dr. Naglaa El-Orabi  Drug interaction Drug interaction Drug-Herb Interactions The use of herbal medications in daily life has become quite prevalent, issues of the safety of coadministration of such products together with therapeutic drugs should be brought into attention. Because herbs are foreign to the human body, it has been suspected that herbal remedies could interact with other herbals or even prescription drugs. Although the pharmacokinetics and pharmacodynamics of drugs are well-known, the activities of any coadministered herbal products have not been well studied due to their complex components and variability.  Drug interaction Drug-Herb Interactions An extensive review of the literature identified reported herb-drug interactions with clinical significance, many of which are from case reports and limited clinical observations. Both pharmacokinetic and/or pharmacodynamic mechanisms have been considered to play a role in these interactions. The clinical importance of herb-drug interactions depends on many factors associated with the particular herb, drug and patient. Interactions between herbal medicines and prescribed drugs can occur and may lead to serious clinical consequences.  Drug interaction Drug-Herb Interactions For example, several herbal products and edible plants like St. John's wort, Anise, Arnica, Capsicum, Celery, Chamomile, Clove, Feverfew, Garlic, Ginger, Horseradish, Rhubarb, Ginseng, Liquorice roots, Ginkgo biloba , Dong quai, meadowsweet, green tea, onion, passion flower, Turmeric, and Wild lettuce are known to contain compounds that enhance or supress the actions of many therapeutic drugs like anticoagulants or antiplatelet potential, contraceptives, antidepressants,…… and many others. Herbs needs to adjust doses, and be appropriately labelled to alert consumers to potential interactions when concomitantly used with drugs, and to recommend a consultation with their general practitioners and other medical carers.  Drug interaction Drug-Herb Interactions 1- St. Jhon’s wort ‫نبتة القديس يوحنا‬ St John’s wort ; hypericum; Hypericum perforatum is one of the most commonly used herbal medicines for the treatment of mild to moderate depression with fewer adverse effects than conventional drugs. It has a complex mixture of > 20 constituents, including flavonols, biflavones, phenylpropanes and others. Among these, hyperforin and pseudohyperforin are the major constituents responsible for its antidepressant activity, that inhibits the reuptake of neurotransmitters (e.g. serotonin, norepinephrine and dopamine) in CNS. Some people try taking St. John's wort as a way of reducing their need for prescription medication. It's important to realize, however, that St. John's wort is an active medication and should be approached the same way as the prescribed pharmaceutical.  Drug Druginteraction interaction Drug-Herb Interactions 1- St. Jhon’s wort Some evidence suggests that taking St. John's wort alone or in combination with black cohosh or other herbs might reduce menopausal symptoms such as hot flushes. Also, St. John's wort might be beneficial for the treatment of emotional distress associated with somatic symptom disorder that causes severe anxiety about physical symptoms such as pain, weakness or shortness of breath. Because of the extensive use and concern of drug interactions, the effects of hypericum on the pharmacokinetics and pharmacodynamics of some clinically important drugs (like Hormonal contraceptives including implants, Cyclosporin and, Antiepileptic drugs) have been investigated clinically.  Drug interaction Drug-Herb Interactions 1- St. Jhon’s wort St John's wort has a pharmacokinetic interactions that it is potent inducer of CYP3A4 and CYP2B6 and many other CYP450 isozymes in a clinically relevant manner, thereby reducing efficacy of co- medications. Hyperforin was a potent ligand for the pregnane X receptor which is an orphan nuclear receptor regulating expression of CYP3A4 and CYP2B6. CYP1A2, CYP2E1, CYP2C9, and CYP2C19 are also affected. Caution to be taken when St. John's wort is coadministered with substrates of these enzymes.  Drug interaction Drug-Herb Interactions 1- St. Jhon’s wort Drugs most prominently affected and contraindicated for concomitant use with St John's wort are metabolised via both CYP3A4 pathway, including HIV protease inhibitors (e.g. Saquinavir, Ritonavir, Nelfinavir) e.g. HIV non-nucleoside reverse transcriptase inhibitors (e.g. Efavirenz, Nevirapine, Delavirdine) , the immunosuppressants Cyclosporin, Mycophenolate and Tacrolimus, and the antineoplastic agents Irinotecan, Docetaxel, Etoposide, and Imatinib mesylate. Efficacy of hormonal contraceptives may be impaired as reflected by case reports of irregular breakthrough bleedings and unwanted pregnancies. Therapeutic efficacies of other drugs like Alprazolam, Midazolam, Phenytoin, Fexofenadine, Methadone, Omeprazole, Theophylline, and Verapamil are also reduced upon coadminsteration. Drugs with a narrow therapeutic index (e.g Digoxin and Warfarin) should be monitored more closely when St John's wort is added, discontinued or the dosage is changed.  Drug-Herb Interactions Dug interaction 1- St. Jhon’s wort St. Jhon’s wort also induces enterocytic P-gp involved in multidrug resistance, acts as a pump to remove drugs from cells both in vitro and in vivo. The induction of intestinal P-gp contributes to the lower oral bioavailability of many drugs like Dihydropyridines, Terfenadine, Saquinavir, Indinavir, Cyclosporin, Midazolam, Triazolam , Digoxin and Verapamil. Pharmacodynamic interactions, when St John's wort is combined with serotonergic agents like Vabicaserin, Buspirone, Triptanes (e.g. Sumatriptanes) and other antidepressants like MAOIs, and TCAs should be restricted to prescription-only, by experienced clinicians, due to potential central pharmacodynamic interactions. It caused serotonin syndrome when coadministered with SSRIs (e.g. Sertaline and Paroxetine), SNRIs (e.g Duloxetine, and Venlafaxine) , TCAs (e.g. Amitriptyline), and MAOIs (e.g. Phenelazine).  Drug interaction Drug-Herb Interactions 1- St. Jhon’s wort Serotonin syndrome is a serious condition that can be fatal without treatment. Symptoms include agitation, confusion, Nausia, Diarrhea, Sweating or shivering, Dilated pupils, Headache, Fever, High blood pressure, Rapid or irregular heartbeat, Involuntary twitching, tremors, Muscle stiffness, Seizures, Loss of consciousness. Hypericin is photosensitizing but generally not a problem with healthy persons. Potential interaction with other photosensitizing drugs like Piroxicam, Chlorpromazine As a clinical strategy, avoid use with other medications unless checked out in an interaction database.  Drug interaction Drug-Herb Interactions 1- St. Jhon’s wort  Drug interaction Drug-Herb Interactions 1- St. Jhon’s wort  Drug interaction Drug-Herb Interactions 2- Garlic ‫الثــوم‬ Garlic (Allium sativum ) It is a commonly used flavoring agent, food product and widely used medicinal herbal supplement. It is reported to have antimicrobial and immune- enhancing effects. In addition, there are many conditions garlic has been promoted to reduce cholesterol and triglycerides, to lower blood sugar levels, and to reduce menstrual pain. Other uses includes effective aid in treating high blood pressure, coronary artery disease, stomach cancer, colon cancer or rectal cancer. Garlic may applied to the skin may also be possibly effective in treating fungal skin infections such as ringworm, jock itch, or athlete’s foot. It is one of the herbal supplements most commonly used by HIV-infected patients to improve health and to treat some opportunistic infections.  Drug interaction Drug-Herb Interactions 2- Garlic Garlic contains high-level sulphur-containing compounds (e.g. allicin and alliin), numerous flavonoids/isoflavonoids (such as nobiletin, tangertin and quercetin), polysaccharides, prostaglandins, saponins and terpenes. Organo -ulfur compounds in garlic are believed responsible for its biological effects. Garlic is often sold as an herbal supplement that sold OTC usually in tablet or capsule form. Suggest enteric coated tablets standardized to about 4mg allicin yield/tablet. Suggested daily dose about 8-12 mg allicin/day (equivalent of about 4g (2-3 cloves) of fresh garlic per day). There are over 180 drug interactions with garlic, but most are reported as minor. It has many reports with pharmacokinetic, and Pharmacodynamic interactions with many codminstered drug. Garlic makes moderate reduction in the activities of many drug-metabolizing CYP 450 system including CYP2E1, CYP3A4, CYP3A5, CYP2C9,CYP2C19, CYP2D6 and CYP3A7. Garlic low-to-moderate induction of activity of enterocytic P-gp transporters activities as well.  Drug interaction Drug-Herb Interactions 2- Garlic One of the major interactions between garlic and blood thinning drugs like Warfarin and fluindone that cotherapy increase the bleeding risk due to increase in plasma levels of drugs. Garlic in combination with anti-HIV drug; Saquinavir (which is a substrate for P-gp, and CYP3A4) should be avoided because garlic reduces the bioavailability of a drug that aid in development of viral resistance against drug. Garlic with antidiabetic; Chlorpropamide and Glibenclamide is a synergistic combination as it increases hypoglycaemic effect of a drug. If anti-TB; Isoniazid is taken with garlic it decreases absorption of isoniazid, so an effect of a drug may decrease. Garlic slightly increases glucuronidation of a therapeutic dose of Paracetamol; after a long period of time the effect of the drug may be decreased. The result shows decreasing the effect of Cyclosporine when taken with garlic.  Drug interaction Drug-Herb Interactions 2- Garlic  Drug interaction Drug-Herb Interactions 3- Ginkgo ‫ الجنكو ذو الشقين‬/ ‫شجرة المعبد‬ Ginkgo (Ginkgo biloba leaf extract ) is one of the most popular herbal traditional Chinese medicine due to its memory-enhancing, cognition-improving and antiplatelet effects. Ginkgo has been used for treating anxiety, dementia, circulation problems in the legs, premenstrual syndrome. The primary constituents of ginkgo include flavonoids (e.g. kaempferol), terpenoids (e.g. ginkgolides and bilobalaides) and organic acids (e.g. ginkgolic acid). Both pharmacokinetics and pharmacodynamic mechanisms of interaction are involved that Ginkgo may alter the metabolism and effectiveness of some prescription and non-prescription medications. High doses of ginkgo could decrease the effectiveness of anticonvulsant therapy, such as Carbamazepine, Phenytoin and Valproic acid , in controlling seizures. This may be due to ginkgotoxin which is a neurotoxin capable of inducing convulsion, and reducing GABA levels and glutamic acid decarboxylase activity.  Drug-Herb Interactions Drug interaction 3- Ginkgo Ginkgo may decrease blood pressure, so use of ginkgo along with prescription antihypertensive medications should be monitored. There has been a report of significant enhancement of the hypotensive effect of Nifedipine. This may be due to ginkgo is a potent peripheral vasodilator. Also ginkgo inhibits intestinal and hepatic CYP3A4 (the main metabolising enzyme of Nifidipine). Ginkgo has blood-thinning properties and therefore should be avoided if taking any of anticoagulant medications, such as Aspirin, Clopidogrel, Dipyridamole , Heparin, Ticlopidine , or Warfarin. Many reports associated concomitant use of ginkgo extract with Warfarin with the development of intracerebral haemorrhage. There is a case report on spontaneous hyphaema when ginkgo extract was combined with Aspirin.Additionally, there is a case report on fatal intracerebral mass bleeding associated with the combined use of ginkgo extract and Ibuprofen.  Drug-Herb Interactions Drug interaction 3- Ginkgo In addition, ginkgo extract enhanced the antiplatelet and antithrombotic effects of Ticlopidine resulting in prolonged bleeding times by 150%. Both pharmacokinetic and pharmacodynamic mechanisms may be involved, given ginkgo extracts can modulate various CYP isoenzymes and exert antiplatelet activity. Ginkgolides are potent inhibitors of platelet-activating factor. There are case reports of post-opoperative haemorrhage caused by ginkgo consumption. Ginkgo may enhance the efficiency and reduce the extrapyramidal adverse effects of the classic antipsychotic Haloperidol in patients with schizophrenia, especially on their positive symptoms. The antioxidant effect of ginkgo is a possible mechanism, as the combination decreased blood superoxide dismutase levels in these patients.  Drug-Herb Interactions Drug interaction 4- Ginseng ‫ نبتة الجنسة السيبيري‬/ ‫الجنسنج‬ Siberian ginseng, the roots of Eleutherococcus senbone is among the ten most popular supplements used in the US. It is a tonic or adaptogen that confers resistance to the effects of stress. The eleutherosides (eleutheroside B , and eleutheroside E )are the major constituents of Siberian ginseng that have been given the most adaptogenic activity. Siberian ginseng extract potentiated the sedative effect of Hexobarbital decreased sleep latency and increased sleep duration. As hexobarbital is mainly metabolised CYP2C9, the interaction may involve CYP2C9 inhibition by Siberian ginseng. There is increase in serum Digoxin concentration when coadministered with Siberian ginseng extract. A recent study indicated that Siberian ginseng contained some digoxin-like constituents interfering with digoxin serum assay results.  Drug-Herb Interactions Drug interaction 5- Red Ginseng ‫ الجنسنج الصيني‬/ ‫باناكس جنسنج‬ Red Ginseng (Root of Panax ginseng) is a widely used herbal medicine because of its purported adaptogenic, anti-fatigue, neuroprotective, antioxidative, sexual stimulants, cognition-enhancing, immuno-enhancing, ulcer-healing, anti-hypertensive, hypolipidaemic, and anticancer effects. Its major constituents include ginsenosides (panoxosides), sterols, flavonoids, vitamins, and minerals. Ginsenosides are considered the pharmacologically active constituents. Ginsenoside Rh2 has Cytotoxic effect against several cancer cell lines. Ginsenoside Rg3 was metabolised to ginsenoside Rh2 and protopanaxadiol by human intestinal microflora. Ginsenoside Rg3 and the resulting metabolites exhibited potent cytotoxicity against tumour cell lines. Although ginseng is well tolerated, some adverse effects like headache, and gastrointestinal disorders.  Drug-Herb Interactions Drug interaction 5- Red Ginseng Ginseng lower the blood ethanol by ~30% This could be due to delayed gastric emptying by ginsenosides, and induction of alcohol oxidising metabolism by CYP2E1. Several case reports have documented suspected interactions of ginseng with the MAOIs antidepressants like Phenelzine. The patients presented with headache, GI disorders, sleeplessness, trembling and manic episodes. with rebound depression symptoms. mechanism underlying may be related to the psychoactive central effects of ginseng. that block the nicotinic acetylcholine receptors, and inhibit the brain voltage-gated sodium channels and inhibit NMDA receptor-mediated signals. Ginseng has the potential to increase bleeding tendency with Warfarin. Both pharmacokinetic and pharmacodynamic components may play a role in ginseng-warfarin interactions. Ginseng extracts have been shown to have antiplatelet effect. Ginsenosides Rg3 and protopanaxadiol-type saponins were found to be have the strongest platelet-activating factor antagonists. In addition, Ginsenoside Rd caused modulation of multiple CYP isozymes involved in Warfarin metabolism like weak inhibitory activity of CYP3A4, CYP2D6, CYP2C19 and CYP2C9. Ginseng enhance the efficacy of various vaccines in protection against infections. Drug-Herb Interactions Drug interaction 5- Red Ginseng  Drug-Herb Interactions Drug interaction 6- Kava ‫الفلفل المس َمم‬ Kava (Piper methysticum (kavain)) is an active herbal medicine for the therapy of anxiety and insomnia. Kava is effective in treatment of anxiety at subclinical and clinical levels like that associated with menopause and various other conditions. The major and pharmacologically active constituents of kava is kavalactones, which are responsible for about 95% of the total activity of kava. The most common effect of kavalactones is inhibitor of CYP1A2, CYP2C9, CYP2C19,CYP2D6, CYP3A4, and CYP2E1. This indicates that kava has a high potential for causing pharmacokinetic drug interactions. In addition, several pharmacodynamic interactions. Coadministration of Alcohol and kava had been shown to have additive hypnotic effects.  Drug-Herb Interactions Drug interaction 6- Kava There is an additive CNS inhibition effects including prolonged sleep and respiratory depression of kavalactones and benzodiazepines like Alprazolam, and Bromazepam since both act on the same GABAA recepors, However, as Alprazolam is a substrate of CYP3A4 and kavalactones are potent inhibitors of CYP3A4, decreased elimination of Alprazolam by kava may contribute to the additive effects reported upon coadministration of kava and Alprazolam. A patient with Parkinson’s disease concomitantly taking Levodopa and kava had increased duration of ‘off’ episodes (persistent Parkinson’s tremor and uncontrolled movements along with other Parkinson’s symptoms). This may be explained by the dopamine antagonistic activity of kava. Kava may increase the risk of extrapyramidal side effects associated with antipsychotic medications (e.g CPZ, Prometahzine) like tardive dyskinesia due to dopamine antagonism. Clinical strategy not to combine kava with alcohol, sedatives, major tranquilizers , anti-Parkinson's drugs , and substrates of CYP450 enzymes.  Drug-Herb Interactions Drug interaction 7- Liquorice ‫العرقسوس‬ Liquorice (Glycyrrhiza glabra ) is a common herb in Chinese, Japaneese, and Egyptian traditional medicine. Liquorice contains glycyrrhizin (glycyrrhizic acid, a glycoside 50 times sweeter than sugar), saponines, triterpe, polyphenols, flavonoids and sucrose. Glycyrrhizin is hydrolysed by intestinal microflora to the pharmacologically active form, glycyrrhetic acid. Liquorice is used as a dietary flavouring agent in candy, beverages, and other foods. Liquorice was used traditionally for treating a variety of conditions, including lung, liver, circulatory, and kidney diseases. digestive problems, menopausal symptoms, cough, and bacterial and viral infections. Liquorice gargles or lozenges have been used to reduce the sore throat that sometimes occurs after surgery. Liquorice is also an ingredient in some products for topical use (application to the skin). Drug-Herb Interactions Drug interaction 7- Liquorice  Drug interaction Drug-Herb Interactions 7- Liquorice Diuretics: (e.g. Furosemide , and Hydrochlorothiazide) Liquorice can cause low blood potassium (hypokalemia), and combining liquorice with diuretics that also decrease blood potassium could cause serious electolyte imbalance Corticosteroids: (e.g. Dexamethasone, Hydrocortisone , and Prednisolone ) Combining a corticosteroid with liquorice could cause low blood calcium (hypocalcimea), edema and increase blood pressure. It may also increase the risk of side effects of the corticosteroid. Digoxin : Liquorice can cause low blood potassium (hypokalemia), which increase the toxicity of Digoxin. Prolonged use of Liquorice extract for 6 weeks of >50 g/day- pseudaldosteronism is produced : Potassium depletion, sodium retention, edema, hypertension and weight gain.  Drug interaction Drug-Herb Interactions 8- Ma Huang (Chinese ephedra) ‫ اإلفيدرا‬/ ‫عشبة العلندة‬ Ma huang is one of the earliest and best known drugs of Chinese traditional medicine. 3 species of ephedra shrubby plant are sources of the drug; Ephedra sinica, E. intermedia, and E. equisetina. Two alkaloids ephedrine and pseudoephedrine, are the major pharmacologically active ingredients of the plants. Even ephedra is banned in many countries like USA, and EU, It still in use in other countries like China and middle eastern countries. Main use of pure ephedrine, and dietary supplements ephedra as the herb is to treat the symptoms of bronchial asthma, colds, and influenza. In addition, use for weight loss and stimulant to increasing athletic performance.  Drug interaction Drug-Herb Interactions 8- Ma Huang Many case with drug interaction with Ephedra have been reported with elevated blood pressure, cardiac arrhythmias, stroke, and even death when ephedra is coadministered with many drugs that have CNS stimulant , direct and indirect sympathomimetic and anticholinergic actions like antihypertension medications, beta blockers (e.g., Propranolol, Metoprolol), MAO inhibitors (e.g. Moclobemide, Phenelzine, Procarbazine), tricyclic antidepressants (e.g. Imipramine, Clomipramine, and nortriptyline), phenothiazine drugs (e.g. Chlorpromazine, Thioridazin), caffeine- containing medications and Theophylline. Cough, cold or allergy medications that may contain Pseudoephedrine or Phenylpropanolamine.  Drug interaction Drug-Herb Interactions 9- Herbal Laxatives Many over-the-counter laxatives contain herbal ingredients. Most laxative herbs contain substances work by various mechanisms like drawing in fluid to the colon and increasing peristalsis. Herbal laxitaves like Senna, buckthorn (Cascara sagrada), Aloe latex, Frangula, Rhubarb , prunes, and many others. As they anhance prestaltic movement, they are shortening the GI transit time of most simultaneously administered drugs and decrease their oral bioavalability and efficacy. In addition, these herbal medications can cause electrolyte imbalance (Sodium and potassium loss that may interfere with or enhance drug toxicities like Digoxin. Long-term use may cause variable degrees of hepatic or renal impairment and can intensify toxicities of many drugs.  Drug interaction Drug-Herb Interactions 10- Warfarin-herb interactions Several herbal products and dietary supplements contain substances that have coumarin, salicylate, or antiplatelet properties. Therefore, a theoretical risk for potentiation of the pharmacologic activity of Warfarin exists when these herbs are coadministered with warfarin. Herbs thought to contain coumarin or coumarin derivatives include Angelica root, Arnica flower, Anise, Celery, Chamomile, Fenugreek, Horse chestnut, Liquorice root, Parsley, Passionflower herb, Quassia, Red and sweet clover. Meadowsweet, Poplar, and willow bark contain high concentrations of salicylates, while clove, onion, and turmeric have been reported to exhibit antiplatelet activity.  Drug interaction Drug-Herb Interactions 10- Warfarin-herb interactions Borage (starflower) seed oil contains glinoleic acid, which may increase coagulation time. Capsicum has been reported to cause hypocoagulability. Feverfew (Tanacetum parthenium) is commonly used for the treatment of migraine headaches, arthritis, and various type of allergies. Parthenolide, is the major sesquiterpene lactone constituent that responsible for the pharmacologic activity. It exert its activity by inhibiting serotonin release, histamine release, prostaglandin synthesis including prostacyclin and thromboxane. It interferes with hemostasis and inhibits platelet aggregation. Feverfew has additive anticoagulant effects in the presence of Warfarin. It is recommended that patients taking Warfarin avoid products containing Feverfew in order to prevent potentially serious bleeding.  Drug interaction Drug-Herb Interactions 10- Warfarin-herb interactions Green tea (Camellia sinensis) is a popular beverage loaded with many bioactive antioxidant constituents like polyphenols, and catechins purported to prevent various cancers, treat GI disorders, enhance cognition and brain function, increase fat burning and metabolism, improve CV and skin health and improve insulin sensitivity and reduce blood sugar levels, immune stimulant and antiaging. Dried green tea leaves have been found to contain substantial amounts of vitamin K. A significant drop in the INR would not generally be expected to result from usual consumption of moderate amounts of brewed green tea. However, patients should be advised that large quantities of green tea might decrease the effectiveness of Warfarin.  Drug interaction Drug-Herb Interactions 10- Warfarin-herb interactions Ginger (Zingiber officinale), promoted for use used for thousands of years for the treatment of numerous ailments, such as colds, nausea, and motion sickness, arthritis, migraines, and hypertension. In addition for being important spice and dietary supplement with many health benefits in many medical tradtionos. It has been reported to reduce platelet aggregation through the inhibition of thromboxane synthetase. Ginger supplements, containing amounts of ginger much greater than regularly found in food products and may lead to an increased risk of bleeding when taken with Warfarin.  Drug interaction Drug-Herb Interactions 10- Warfarin-herb interactions Patients taking any products containing all of these herbs concurrently with anticoagulant medications, such as warfarin, should be closely monitored for symptoms of bleeding and the INR should be closely monitored.  Drug interaction Drug-Herb Interactions Several hundreds of other herbs world-wide with / without enough data about their drug interactions. Patients on complicated medical regimens should avoid herbs and supplements unless carefully screened/supervised, but prioritize drugs with narrow therapeutic index, like : Carbamazepine, Cyclosporine, Digoxin, Ethosuximide, Levothyroxine, Phenytoin, Procainamide, Theophylline and Warfarin  Drug interaction Drug-Herb Interactions Checking for more information Natural Standard (www.naturalstandard.com). Subscription service. Partial database at MedlinePlus.gov Natural Medicines Comprehensive Database (www.naturaldatabase.com). Subscription service. Lexi-Interact. Subscription service (www.lexi-comp.com) MicroMedex – Altmedex. Subscription service (www.micromedex.com) Some subscription services give indications of interactions according to class of drugs and may thus be excessively broad in definitions of interactions. 18 Herbal Supplements with Risky Drug Interactions (drugs.com) Potential Interactions - Alternative Therapies and Warfarin (medscape.com) Drugs 2005; 65 (9): 1239-1282 REVIEW ARTICLE Medicines 2021, 8, 44. https://doi.org/10.3390/medicines8080044 Medicines : Herb–Drug Interactions: Worlds Intersect with the Patient at the Center | HTML (mdpi.com) Handbook of Drug Interactions | SpringerLink18 Herbal Supplements with Risky Drug Interactions Drug Interactions: Scientific and Clinical Principles by Gabay M. et al,  Drug interaction Drug-Food Interactions A drug-food interaction happens mainly with those drugs administered orally when the food affects the ingredients in a medicine you are taking so the medicine cannot work the way it should. Drug-food interactions can happen with both prescription and over-the-counter medicines, including antacids, vitamins and iron pills. Affected Drug Interacting Food Interaction - Anti osteoporosis like Any food contents in the Food, even juices, coffee, Bisphosphonates (such as stomach or tea may markedly reduce Alendronate, Ibandronate, the absorption and and Risedronate) effectiveness of these drugs. must be taken on - Antibiotics, antibacterials empty stomach with plain (such as Ampicillin, water at least ½-1 hour Tetracycline, Rifampicin, before the first food, and Sulfamethoxazole) beverage, or drug of the day is taken, and. - Cancer chemotherapeutic agents (such as Methoteraxate, and Mycofenolate)  Drug interaction Drug-Food Interactions Affected Drug Interacting Food Interaction Anticoagulants such as Foods high in Such foods may reduce Warfarin and vitamin K (such as the effectiveness of Coumarin liver, broccoli, anticoagulants brussels sprouts, increasing the risk of. spinach, and most of clotting. Intake of such leafy vegetables) foods should be limited, and the amount consumed daily should remain constant.  Drug interaction Drug-Food Interactions Affected Drug Interacting Interaction Food ▪ Certain Grapefruit Grapefruit juice inhibits enzymes benzodiazepines juice involved in drug metabolism ( (such as Triazolam) mainly CYP3A4)and thereby ▪ Calcium channel intensifies the effect or toxicity of blockers (such as many drugs Felodipine. Nifedipine,,and Nisoldipine) ▪ Cyclosporine ▪ Estrogen and oral contraceptives ▪ Certain statins (such as Atorvastatin, Lovastatin, and Simvastatin)  Drug interaction Drug-Food Interactions Affected Drug Interacting Food Interaction Digoxin Oatmeal, cereals, bran, The fiber in oatmeal and and all fiber-containig other cereals, when food consumed in large amounts (due to high fiber contents), can interfere with the absorption of digoxin.  Drug-food interactionz Drug-Food Interactions Affected Drug Interacting Food Interaction Some Digoxinantibiotics Calcium Oatmeal,orcereals, foods These foods The fiber can reduce in oatmeal like Tetracycline, containing calcium, bran, and all fiber- the absorption and other cereals, when of Quinolones, and such as milk containig and other food antibiotics due consumed in large to Azithromycin dairy products chelation amounts (due to high or complexation, fiber contents), canwhich should interfere with the hour be taken 2 before or 2ofhours absorption after digoxin. eating.  Drug interaction Drug-Food Interactions Affected Drug Interacting Food Interaction MAO inhibitors Foods high in tyramine, Severe headache and a antidepressants including many potentially fatal (such as cheeses (such as increase in blood Phenelzine American processed, pressure (hypertensive and cheddar, blue, crisis) can occur if Tranylcypromine) mozzarella, and people taking an MAO Parmesan), yogurt, inhibitor (consume sour cream, cured these foods. These meats (such as sausage foods must be avoided and salami), liver, (cheese reaction). dried fish, pickeled herring, caviar, avocados, bananas, yeast extracts, raisins, soy sauce, fava beans, red wine, certain beers, and products containing caffeine like chocolate