Food-Drug Interactions 2024-25 AK PDF

Food-Drug Interactions  Objectives 1. Define the term and describe classes of drug/ nutrition, and food/ drug interactions 2. Provide specific examples that could be seen in clinical practice 3. Describe nutrient–drug interactions involving certain foods, e.g. gra...

Food-Drug Interactions  Objectives 1. Define the term and describe classes of drug/ nutrition, and food/ drug interactions 2. Provide specific examples that could be seen in clinical practice 3. Describe nutrient–drug interactions involving certain foods, e.g. grapefruit juice, ginger, and Licorice 4. Discuss means of identifying and appropriately managing clinically important drug-nutrient interactions.. 5. Explain the role of clinical pharmacist in identifying and managing drug-nutrition interactions  Drug-Nutrition Interaction An interaction resulting from a physical, chemical, physiologic relationship between a drug and a nutrient, food in general How Drugs and Food Interact Foods (or nutrients) can affect the action of medications changing how they work. Drugs (prescription and OTC) can affect the way the body utilize nutrients in food. Thus, can lead to nutritional deficiencies. How Does This Occur? https://www.sciencedirect.com/science/article/abs/pii/S0002822311015446  Pharmacokinetic interactions Caused by physicochemical properties of food products It changes in the pharmacokinetics of drugs by chemically binding to the drug and converting it into an insoluble salt that is not easily absorbed. Proteins in the food bind to the antiepileptic agent, phenytoin, resulting in reduced phenytoin absorption and potentially inadequate seizure control. Tetracyclines can bind to divalent cation-containing products (e.g., calcium in dairy) resulting in reduced drug absorption and potential therapeutic failure. Foods rich in fat can increase drug absorption by improving the solubility of lipid soluble drugs, such as some antiretroviral protease inhibitors (e.g., saquinavir and atazanavir). Food products may also affect drug absorption by delaying gastric emptying, stimulating bile, increasing/decreasing GI pH.  Pharmacodynamic interaction Some foods attenuate or enhance drug effects and toxicity by interfering with drug actions, mechanisms and the pharmacodynamics of the drug. The anti-coagulant warfarin antagonizes vitamin K1 recycling leading to the depletion of active vitamin K1. (green leafy vegetables contain large amounts of vitamin K1) Renin-angiotensin system inhibitors increase plasma potassium [K+] levels due to a reduction in aldosterone activity. However, foods rich in [K+] such as oranges and bananas may cause hyperkalemia resulting in cardiac arrest and death due to myocardial arrhythmia. A hypertensive crisis can result from the ingestion of tyramine-rich foods (cheese) in conjunction with monoamine oxidase inhibitors (MAOIs). MAOIs, used to treat depression, inhibit the breakdown of endogenous and dietary amines. Consequently, MAOIs reduce the breakdown of tyramine, a precursor of catecholamines (endogenous vasoconstrictors), and raise catecholamine biosynthesis causing a hypertensive crisis  Food-Drug Interactions A food-drug interaction is the effect of food or nutrients on a medication. Some drugs are absorbed more quickly when stomach is empty, one hour before or two hours after eating but sometimes a medication should be taken with food. It is important to read the directions Certain medicines can irritate the stomach. Thus, such medicines are suitable to be taken after food. i For example: acetylsalicylic acid, non- steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac and ibuprofen  E levothyroxine (Synthroid, Levoxyl, Tirosint) Used in the morning on an= empty stomach. That’s because certain foods and drinks like, walnuts, high-fiber foods, and soybean flour affect itsE absorption. As well as the common breakfast drinks, like grapefruit juice, coffee, and milk. - Alendronate - - (Fosamax), example of bisphosphonates that help prevent bone breakdown and is used to treat osteoporosis. Some foods can attach to bisposphonates in your stomach which interferes with absorption. - Although many drug interactions with fruit juices are not considered clinically relevant, there still are some that deserve our attention. The best advice is to take the medication with water. Caffeine can stimulate the central nervous system and increase blood pressure as well as attributing some diuretic effect. A number of drugs can interfere and subsequently increase the caffeine level in blood; examples are ciprofloxacin, cimetidine and oral contraceptives Apple juice and orange juice compete with drugs to be absorbed, resulting in lower level of drugs being absorbed into the blood stream. Absorption of fexofenadine (an antihistamine), is modestly reduced when taken with orange juice and apple juice. Dietary calcium can bind to the antibiotic tetracycline. As a result, the body does not absorb the amount of antibiotic intended. Foods may interfere with a drug’s metabolism or action in the body. Example: Aged and fermented foods (such as cheeses) contains tyramine that interacts with monoamine oxidase inhibitors and result in dangerously high blood pressure. Example: Vitamin K can decrease the effectiveness of certain anticoagulant medications.  Dietary Effect on Metabolism ⑮ CYPs are responsible for almost 75% of overall drug metabolism. There are various factors affecting the activity and expression of O to e CPYs including age, gender, ancestry, body and dietary intake weight, co-medications Studies have demonstrated that Calorie-restricted diets suppress the activity of CYPs and high calorie intake increases its rate. High content of protein in diet or a high-fat diet enhance the activity of certain CYPs through an increased blood flow into the liver Short-term fasting decreases the activity of CYP2C9, however, increases the activity of CYP2D6 and CYP1A2. The activity of CYP1A2 increased by a high protein diet and fasting, but reduced by - high carbohydrate diet. The activity of CYP2C9 is decreased by fasting and increased by obesity.  Effect of enteral or parenteral nutrition e - # Re-feeding undernourished patients increases systemic clearance necessitating a~ dosage adjustment to - & maintain efficacy. The protein component of enteral or parenteral nutrition is the major macronutrient enhancing systemic clearance. Examples Theophylline (relax muscles around airways to aid breathing asthma ) In undernourished patients üthe volume of distribution decreases Administering a glucose-based solution as part of parenteral nutrition can have acute effects on the disposition of theophylline Phenytoin (anticonvulsant) When given with continuous enteral nutrition a decrease in serum phenytoin level is noted Protein component of enteral nutrition binds to phenytoin and prevents its absorption from the gastrointestinal tract. This occurs with both capsules and suspension  Examples Warfarin (anticoagulant) Certain enteral nutrition formulas may interfere with warfarin absorption in the gastrointestinal tract, potentially affecting its efficacy. Close monitoring of the patient's response to warfarin, regular INR checks, and adjustments in warfarin dosing to maintain the desired level of anticoagulation and ensure patient safety.  Nutritional status significantly affect a drug’s pharmacokinetics and pharmacodynamics  Food-Drug Interactions with Grapefruit Juice Grapefruit juice is one of the most widely studied examples of food-drug interactions. Potential interaction like certain statins (simvastatin), calcium channel blockers, and anticoagulants (warfarin), benzodiazepines, can significantly increase the levels of these drugs in the bloodstream and increase the risk of side effects. deMiligy j Bergamottin, a- * furanocoumarin component of grapefruit juice, is a clinically known inhibitor of CYP3A4 which, mainly involved in the & - pharmacokinetic interactions leading to increased side effects and toxicity of co-administered drugs Pharmacokinetic interaction (ADME) -  Food-Drug Interactions with Grapefruit Juice. e mub Decreases the plasma concentrations of the antihistamine (fexofenadine) and β-blocker (celiprolol) possibly by inhibiting intestinal uptake transporters. Slightly delay the absorption of levothyroxine. Patients taking the antibiotic erythromycin and consuming grapefruit juice have an increased risk for cardiovascular symptoms, including cardiac dysrhythmias. New interactions are continuously being reported. Effects can last an extended period of time, so they don't have to be taken at the same time with medication for interaction to occur. Therefore, grapefruit juice should not be consumed when taking drugs that are affected by it.  Food-Drug Interactions with Ginger Medications that slow blood clotting (Anticoagulant / Antiplatelet drugs) interacts with Ginger Taking ginger along with medications that also slow clotting might increase the chances of bruising and bleeding. Some medications that slow blood clotting include: Aspirin, clopidogrel (Plavix), diclofenac (Voltaren, Cataflam, others), ibuprofen (Advil, Motrin, others), naproxen (Anaprox, Naprosyn, others), dalteparin (Fragmin), enoxaparin (Lovenox), heparin, warfarin (Coumadin) In some cases, ginger used along with other herbs and supplements that also slow blood clotting increase the risk of bleeding (Angelica, clove, garlic, ginkgo, Panax ginseng, red clover, turmeric)  Medications for high blood pressure (Calcium channel blockers) interact with Ginger Ginger might reduce blood pressure in a way that is similar to some medications for blood pressure and heart disease. Taking ginger along with these medications might cause blood pressure to drop too low or an irregular heartbeat. Some medications for high blood pressure and heart disease include: Nifedipine (Adalat, Procardia), verapamil (Calan, Isoptin, Verelan), diltiazem (Cardizem), isradipine (DynaCirc), felodipine (Plendil), amlodipine (Norvasc), and others.  Medications for diabetes (Antidiabetic) interact with Ginger Ginger might decrease blood sugar. Taking ginger along with diabetes medications might cause blood sugar to go too low. Therefore, blood sugar needs to be monitored closely. Some medications used for diabetes include: glimepiride (Amaryl), glyburide (DiaBeta, Glynase PresTab, Micronase), insulin, pioglitazone (Actos), rosiglitazone (Avandia), chlorpropamide (Diabinese), glipizide (Glucotrol), and others  s is Food-Drug Interactions with Licorice e A total of 142 drugs are known to interact with licorice. - -138 moderate drug interactions 4 minor drug interactions - Full list at: https://www.drugs.com/drug-interactions/licorice-index.html  Food-Drug Interactions with -Licorice ent - Products containing licorice (glycyrrhizic acid) can cause high - blood pressure as well as salt and water retention, which may interfere with the effects of various drugs. Generally, patients should avoid or limit the consumption of licorice if they have- 00 high blood pressure, heart failure, pulmonary -hypertension (high blood pressure in the vessels of the lung), or kidney disease. & A  Food-Drug Interactions with Licorice Regular use of licorice may also cause loss of magnesium and potassium, increasing the risk that toxic effects of drugs like digoxin Licorice may increase effects of other drugs like Cisplatin, and cause low blood potassium levels Patients may need a dose adjustment or special test if Licorice is used with Cisplatin. The FDA warning: "If you'reO40 or older, eating 2 ounces of black - licorice a day for at least two weeks could land you in - the hospital with an irregular heart rhythm." -  Food-Drug Interactions with Ginseng O 1 major drug interaction 102 moderate drug interactions Full list at: https://www.drugs.com/drug-interactions/ginseng-index.html?filter=3 Food-Drug Interactions with Ginseng Co-administration of ginseng with imatinib may increase the plasma concentrations and risk of adverse effects associated with imatinib Monitor patients closely for signs and symptoms of imatinib- induced toxicity (e.g., hepatotoxicity) during co- administration with ginseng.  Food-Drug Interactions with Ginkgo Biloba There are 298 drugs known to interact with Ginkgo Biloba (ginkgo). All interactions are moderate.  Food-Drug Interactions with Ginkgo Biloba Anticonvulsant medications High doses of ginkgo could decrease the effectiveness of anticonvulsant therapy, such as carbamazepine (Tegretol) or valproic acid (Depakote), in controlling seizures. Ginkgo contain varying amounts of 4'-O-methylpyridoxine (ginkgotoxin), a known neurotoxin in ginkgo seeds but also in lesser amounts in the leaves. In vivo, 4'-O-methylpyridoxine competes with vitamin B6, which causes an indirect inhibition of glutamate decarboxylase and subsequent decrease in the formation of gamma-aminobutyric acid (GABA) in the brain. Antidepressant medications Taking ginkgo along with selective serotonin reuptake inhibitor (SSRIs) antidepressants ex. fluoxetin (Prozac), may cause serotonin syndrome. Antihypertensive medications Ginkgo may decrease blood pressure, so use of ginkgo along with prescription antihypertensive medications should be monitored by a health care provider. There has been a report of an interaction between ginkgo and nifedipine (Procardia), a calcium channel blocking drug used for blood pressure and arrhythmias. Blood-thinning medications Ginkgo has blood-thinning properties and therefore should not be used if you are taking anticoagulant medications, such as aspirin, clopidogrel (Plavix). Blood sugar lowering medications: Ginkgo supplements should only be used under the supervision of a health care provider in diabetics taking insulin or oral blood sugar lowering drugs. Thiazide diuretics: There has been one literature report of increased blood pressure associated with the use of ginkgo during treatment with thiazide diuretics, this interaction has not been verified by clinical trials. Nevertheless, health care provider should be consulted before using ginkgo while taking thiazide diuretics.  Effects of food and nutrients on drugs If You Take: Be Careful With: Because: Analgesic and anti- Administration can irritate the inflammatory agents: with food. stomach. Thus, such medicines are suitable Aspirin, Ibuprofen, to be taken after food. Indomethacin, Acetaminophen  Effects of food and nutrients on drugs If You Take: Be Careful With: Because: Antibiotics: Acidic foods: Increase stomach caffeine drinks, acid may increase Penicillin tomatoes, fruit juice. destruction of this Erythromycin drug in the stomach. Tetracycline Foods rich in calcium: milk, cheese, ice cream, Calcium, iron yogurt. preparations and some antacids decrease absorption Don’t avoid milk of the drug or render products but take them at it ineffective, a different time. probably due to chelation.  Effects of food and nutrients on drugs If You Take: Be Careful With: Because: Anti-depressants: Tyramine-rich foods: Tyramine may cause MAO aged cheese, potentially lethal (monoamine avocados, wine, sour increases in blood oxidase inhibitors) cream, chicken livers, pressure, fever, yeast products, pickled terrible headache, herring. vomiting, possibly death. Excessive caffeine: chocolate, tea, coffee.  Effects of food and nutrients on drugs If You Take: Be Careful With: Because: Broncho-dilators: Charcoal-broiled Too much charcoal and Theophylline foods and high carbohydrates and carbohydrate diet. protein decreases absorption. -Large amounts of high protein foods: Protein also increases meat, milk, eggs, the metabolism of the cheese. drug.  Effects of food and nutrients on drugs If You Take: Be Careful With: Because: Parkinson’s Foods rich in vitamin B6: B6 antagonizes the medications beef liver and yeast drug. (L-Dopa) products. Levodopa  Effects of food and nutrients on drugs If You Take: Be Careful With: Because: Anti- Green leafy -These foods contain vitamin K coagulants: vegetables, beef (promotes blood clotting), which liver, broccoli, interfere with the effect of the Dicumarol, asparagus, tomato, blood thinner. Coumadin coffee Mineral oil -Mineral oil decreases the absorption of vitamin K and may increase the effect of the anticoagulant.  Effects of food and nutrients on drugs If You Take: Be Careful With: Because: Anti-hypertensives Natural licorice. Natural licorice Foods with - contains a substance excessive sodium: that causes excessive cured meats, pickled loss of K +, water vegetables, canned and Na retention and soups, processed thereby increased foods, especially blood pressure. cheese, salted snacks, added salt at table.  Effects of food and nutrients on drugs If You Take: Be Careful With: Because: Corticosteroids: -Natural licorice This class of drugs Prednisone, -Foods high in causes increased Solu-medrol, sodium: cured sodium and water Hydrocortisone meats, pickled retention leading to vegetables, canned edema. soups, processed foods, especially cheese, salted snacks, added salt at table.  Effects of food and nutrients on drugs If You Take: Be Careful With: Because: Diuretics: -Natural licorice -Diuretics may cause excessive (Potassium losses of potassium and severe Wasting) electrolyte disturbances; also Modiuretic, loss of vitamin B complex, Naqua, Lasix, magnesium, calcium. Oretic  Effects of food and nutrients on drugs If You Take: Be Careful With: Because: Diuretics: -Potassium-rich foods: -May cause excessive (Potassium bananas, figs, wheat germ, retention of potassium Sparing) orange juice (2 or 3 and cardiac problems. Dyrenium, glasses), salt substitutes, Salt substitutes may Aldactone Monosodium glutamate contain potassium (MSG), sodium-rich foods. rather than sodium.  Effects of food and nutrients on drugs If You Take: Be Careful With: Because: Laxatives: Dulcolax -Milk -Laxative becomes ineffective and causes stomach irritation.  Effects of food and nutrients on drugs If You Take: Be Careful With: Because: Iron supplements -Taking with bran, or -These minerals and with calcium, zinc or bran make iron copper supplements. unavailable.  II. Drug-Food Interaction A drug-food interaction is the effect of a medication on nutrients in food. Medications can: Decrease appetite and intake. Change the way a nutrient is absorbed or excreted. Change the way a nutrient is metabolized. Example: Cancer medications may cause nausea, vomiting, sore or dry mouth resulting in poor intake. This does not mean that while taking a medication, there is a need to use a vitamin and or mineral supplement.  There is little chance that medication for a short time, (eg; ten days) will affect nutritional status. However, months or years may have an affect nutritional status. Changing the diet to include food rich in vitamins/minerals is preferred to supplementation. In fact, vitamin/mineral supplements taken in excess can affect how a medication works.  Nutrient Supplements Supplements can result in drug-food interactions. Vitamins/minerals act like drugs in excessive amounts. Nutrients in excessive amounts may interact with other nutrients or even be toxic. Example: Large amounts of zinc can interfere with iron and copper absorption. Similarly, large amounts of iron can interfere with zinc absorption.  Drug Effect on Food Absorption Laxatives can decrease the absorption of many vitamins/minerals due to rapid movement. Aluminum hydroxide in antacids can bind to phosphorus. This prevent phosphorus absorption and bone weaken due to phosphorus depletion. Mild depletion causes muscle weakness and severe cases causes osteomalacia and pain during walking.  Drug Effect on Food Absorption Anticonvulsants can decrease folate absorption resulting in megaloblastic anemia. Some cholesterol lowering medications reduce cholesterol by removing bile acids. Bile acids are needed to absorb fat-soluble vitamins A, D, E, and K. As a result, it can reduce absorption of these fat- soluble vitamins.  Drug Effect on Nutrient Production Vitamin K and biotin are produced by bacteria in the intestines. Antibiotics kill harmful bacteria, but they can also kill helpful bacteria leading to the decrease of vitamins produced in the intestine. Drug Effect on Nutrient Metabolism Birth control pills can lower levels of vitamin B6 and folate in the body. Anticonvulsant medications increase liver removal of vitamin D from the body by interfering with its activation. Vitamin D is needed for calcium absorption.  Drug Increase Nutrient loss Large amounts of aspirin can cause increased loss of folate. Also, over long periods of time may cause stomach bleeding and iron deficiency anemia. Diuretics remove excess fluid from the body. Some diuretics may also increase loss of potassium along with fluids. Potassium is needed for proper functioning of the heart and muscles.  Effects of drugs on food or nutrients If You Take: You May Require Extra Because: Analgesics: Vitamin C, folate, -Aspirin increases Salicylates vitamin K. loss of vitamin C (aspirin) and competes with folate and vitamin K.  Effects of drugs on food or nutrients If You Take: You May Require Extra Because: Antacids -Thiamin -Inactivates thiamin. Taken at a different time. -Magnesium, -These drugs cause phosphorus, iron, decreased absorption vitamin A and folate. of these nutrients. Depending on type of antacid. Effects of drugs on food or nutrients If You Take: You May Require Because: Extra Antibiotics -Vitamins K and -Appetite biotin suppression and diarrhea. -Inhibition of synthesis by bacterial flora. Effects of drugs on food or nutrients If You Take: You May Require Extra Because: Alcohol -Vitamin B12, folate, -Turnover of these Particularly thiamin, magnesium. nutrients increases excessive use. -Food intake decreases. Effects of drugs on food or nutrients If You Take: You May Require Extra Because: Anticancer drugs -Nutrients -Cancer cachexia. -Increased losses. -Decreased intake and utilization.  Effects of drugs on food or nutrients If You Take: You May Require Extra Because: Anticholinergic: -Fluids -Saliva thickens Elavil, Thorazine and loses its ability to prevent tooth decay.  Effects of drugs on food or nutrients If You Take: You May Require Because: Extra Anti- -Folate, -Decreased absorption of convulsants folate, leading to vitamin D. megaloblastic anemia. -Increases turnover of vitamin D, especially in children.  Effects of drugs on food or nutrients If You Take: You May Require Extra Because: Anti-depressants: -Water Cause a metallic Take with food. taste, nausea, vomiting, dry mouth, Lithium carbonate, Lithane, Lithobid, loss of appetite, Lithonate, Lithotabs, weight gain and Eskalith increased thirst. S.Bahijri  Effects of drugs on food or nutrients If You Take: You May Require Extra Because: Sedatives: Folate, vitamin D, Drugs increase the Barbiturates vitamin B12, thiamin, rate these vitamins vitamin C are used by the body. Effects of drugs on food or nutrients If You Take: You May Require Extra Because: Anti-inflammatory -Folate These medications agents decrease folate absorption. Effects of drugs on food or nutrients If You Take: You May Require Because: Extra Cholesterol- -Fat-soluble -May cause lowering vitamins: A, D, E, decreased medications: K, folate, iron absorption of these Questran vitamins and minerals.  Effects of drugs on food or nutrients If You Take: You May Require Extra Because: Corticosteroids: -Protein, potassium, -These drugs cause an Prednisone, Solu- calcium, magnesium, increase in excretion. medrol zinc, vitamin C, Hydrocortisone vitamin B6  Effects of drugs on food or nutrients If You Take: You May Require Extra Because: Diuretics: Potassium -Potassium, calcium, -These drugs cause an wasting; Naqua, magnesium, zinc increase in excretion Lasix, Oretic of these minerals.  Effects of drugs on food or nutrients If You Take: You May Require Extra Because: Mineral oil -Fat-soluble vitamins: -Mineral oil decreases A, D, E, and K; absorption of these calcium, phosphorus, vitamins and potassium minerals.  Effects of drugs on food or nutrients If You Take: You May Require Extra Because: Oral contraceptives -Vitamin B6 and -They may cause folate. selective malabsorption or increased metabolism and turnover.  The role of clinical pharmacist in identifying and managing drug-nutrition interactions Use the framework to optimize patient outcome Clinical observation, analysis, and documentation üIs my patient’s change in nutritional status related to an interaction? üIs my patient’s unexpected drug effect related to an interaction?  Who is at Risk of Drug-Nutrient Interactions? Some people may be at greater risk of drug-food interactions than others. Those include: Persons with poor diet. Persons with serious health problems. Growing children. Pregnant women. Older adults.  Patient Approach to Minimizing Risk Who – Coordinated, interdisciplinary, team-based approach is considered critical to managing patients with potential drug-nutrition interactions How– Decision support systems integrated into screening tools and ordering systems could be valuable Steps üThorough patient assessment – History and physical examination üIdentify risk potential for interaction – Based on risk factors üPlan to manage– Close monitoring– Adjust regimen – Document Drug – Nutrient interaction checker https://www.integrativepro.com/drug-nutrient-interaction-checker https://www.drugs.com/drug_interactions.html