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3.8. Ismail, 2009. Drug Interaction Food
3.8. Ismail, 2009. Drug Interaction Food
Review Article
ABSTRACT
Interaction between foods and drugs can have profound influence on the success of drug treatment and on the side
effect profiles of many drugs. The clinical significance of drug-food interactions can be variable. Drug-food
interactions can lead to a loss of therapeutic efficacy or toxic effects of drug therapy. Generally, the effect of food
on drugs results in a reduction in the drug's bioavailability; however, food can also alter drug clearance. Some
foods greatly affect drug therapy, resulting in serious side effects, toxicity, or therapeutic failure. In some
instances, the interaction may have a beneficial effect by increasing drug efficacy or diminishing potential side
effects. Pharmacists in every practice setting need to be vigilant in monitoring for potential drug-food interactions
and advising patients regarding foods or beverages to avoid when taking certain medications. It is imperative for
pharmacists to keep up-to-date on potential drug-food interactions of medications, especially today’s new drugs,
so that they may counsel properly to the patients.
Erythromycin Unknown.
and possible toxicity. Children are more prone to this interaction than adults.
Table 2: Some examples of drug-food interactions that delay the absorption of drugs
Digoxin High–fiber, Take drug same time with relation to food, Avoid
high–pectin taking with high-fiber foods.
foods bind drug.
Glipizide Mechanism Affects blood glucose; more potent when taken half
unknown. hour before meals.
Penicillamine May form Avoid taking with dairy products or iron–rich foods or
chelate with supplements.
calcium or iron.
Quinidine Possibly protein May take with food to prevent gastrointestinal upset
binding.
Tetracyclines Binds with Take one hr before or two hr after meals; do not take
calcium ions or with milk.
iron salts
forming
insoluble
chelates.
Asian Journal of Pharmaceutical and Clinical Research
Vol.2 Issue 4, October.-December. 2009
Cimetidine, Famotidine, Avoid high protein foods, caffeine and other items that increase
Sucralfate stomach acidity.
Hormone Preparations
Oral contraceptives Salty foods increase fluid retention. Drugs reduce the absorption
of folate, vitamin B6 and other nutrients; increase intake of foods
high in these nutrients to avoid deficiencies.
Steroids Salty foods increase fluid retention. Increase intake of foods high
in calcium, vitamin K, potassium and protein to avoid
deficiencies.
Thyroid drugs Iodine-rich foods lower the drug's efficacy.
Laxatives
Mineral Oils Overuse can cause a deficiency of vitamins A, D, E, and K.
Painkillers
Aspirin and stronger Always take with food to lower the risk of gastrointestinal
nonsteroidal anti- irritation; avoid taking with alcohol, which increases the risk of
inflammatory drugs bleeding. Frequent use of these drugs lowers the absorption of
folate and vitamin C.
Codeine Increase fiber and water intake to avoid constipation.
Sleeping Pills, Tranquilizers
Benzodiazepines Never take with alcohol. Caffeine increases anxiety and reduce
drug's effectiveness.
In other cases, the components of the food, fat in a meal. Fenofibrate, mebendazole,
such as calcium or iron, may form isotretinoin, tamsulosin, carbamazpine and
complexes with the drug that are less labetalol are examples of drugs that will be
easily absorbed. Examples include better absorbed when taken with food.
tetracycline, sodium fluoride and Improved absorption of a drug may or may
ciprofloxacin .The absorption of not have a significant effect on the drugs
alendronate is impaired by food, calcium efficacy.6 Patients taking digoxin should
and almost everything, including orange avoid taking bran fiber, pectin-containing
juice and coffee. It should be taken with foods such as apples or pears, or fiber-
plain water and nothing else should be containing, bulk-forming laxatives at the
consumed for at least 30 minutes. In many same time, since these agents may bind to
cases, the actual mechanism by which food the digoxin, decreasing its absorption. This
interferes with absorption is not known. interaction could result in decreased serum
Delayed absorption does not necessarily concentrations of digoxin and therapeutic
reduce the total overall exposure to the effectiveness. It is advisable to take some
drug; the area under the curve (AUC) may medications with food to reduce
be equivalent regardless of how the drug is gastrointestinal irritation and possible
taken. A reduced rate of absorption may nausea. Examples of these medications
sometimes be useful in reducing the side include potassium supplements, ferrous
effects of a drug, as in the cases of sulfate, nonsteroidal anti-inflammatory
ibuprofen, without reducing drugs, estrogen, prednisone, tacrine,
bioavailability. The bioavailability of some terfenadine and nitrofurantoin.
drugs may be enhanced by food. For Cholesterol-lowering agent lovastatin
example, an acid environment is necessary should be taken with food to enhance
for the absorption of ketoconazole. The gastrointestinal absorption and
absorption of griseofulvin is increased by bioavailability. Simvastatin, pravastatin
Asian Journal of Pharmaceutical and Clinical Research
Vol.2 Issue 4, October.-December. 2009
and fluvastatin may be taken without oxidase and this prevents tyramine from
regard to food.2, 4 Examples of some drug- accumulating in the body. Monoamine
food interactions which accelerate and oxidase inhibitors cause increased levels of
delay the absorption of drugs are shown in tyramine which can lead to a hypertensive
table 1 and table 2 respectively with the crisis. Patients taking monoamine oxidase
brief counseling. inhibitors should avoid foods high in
tyramine such as aged cheeses, pickled
Drug Metabolism Interactions fish, yeast extracts, red wine, some types
of beer (including nonalcoholic beer), fava
Food may alter the hepatic beans and fermented products. High-
metabolism of some drugs. It has been protein foods that have been aged,
reported that when administered with the fermented, pickled, smoked or bacterially
antihypertensive drug felodipine, contaminated are unsafe for patients taking
concentrated grapefruit juice caused an MAO inhibitors. Foods considered safe
increase in the bioavailability of when used fresh and in moderation include
felodipine. The mean felodipine sour cream, yogurt, meat extracts, chopped
bioavailability with grapefruit juice was liver, dry sausage and alcoholic beverages.
284% (range 164%–469%) that of water. 9-12
This resulted in lower diastolic blood
pressures and increased heart rate in the Drug Excretion Interactions
male study volunteers. Adverse effects
such as headaches, facial flushing and Foods may alter the urinary pH,
lightheadedness were more common after which can affect the activity of certain
ingestion of 250 ml grapefruit juice (125 drugs. The half-lives of some medications
ml frozen grapefruit concentrate plus 125 can be significantly changed by alterations
ml of water). The bioavailability of in urinary pH. Therefore, the half-life of
nifedipine with grapefruit juice was 134% acidic drugs will be extended in acidic
(range 108%–169%) of that with water. urine because the drug is in its unionized
Orange juice did not have these effects. It form. However, the half-life of an acidic
is postulated that flavonoid compounds in drug in alkaline urine is reduced because
grapefruit juice concentrate inhibit the drug is in its ionized form. Foods such
cytochrome P-450 metabolism of as milk, vegetables and citrus fruits can
felodipine and nifedipine. This interaction alkalinize the urine. Meats, fish, cheese
could increase both the efficacy and and eggs can acidify the urine. Foods may
toxicity of these calcium channel blockers. alter the renal excretion of some
There is potential clinical significance medications. Lithium and sodium compete
because citrus juices are frequently for tubular reabsorption in the kidney. A
consumed at breakfast, when many high-salt diet causes more lithium to be
medications are also taken. Patients should excreted, whereas a low-salt diet causes
be advised of this possible interaction.7, 8 decreased renal excretion of lithium and an
First-pass hepatic metabolism of increase in serum lithium levels.6
propranolol and metoprolol may be
decreased when either medication is taken Pharmacodynamic Interactions
with food, thereby enhancing
bioavailability. Drug levels and therapeutic Foods may interact with medications by
efficacy may be increased due to this altering their pharmacologic actions. Diets
interaction. Monoamine oxidase (MAO) high in vitamin K may cause antagonism
inhibitors are known to interact with foods of warfarin and decreased therapeutic
containing tyramine. Tyramine is normally efficacy of the anticoagulant. Foods rich in
inactivated by the enzyme monoamine vitamin K include green leafy vegetables
Asian Journal of Pharmaceutical and Clinical Research
Vol.2 Issue 4, October.-December. 2009
(kale, turnip greens, spinach, broccoli and an adverse side effect or toxicity or may
brussels sprouts), cauliflower, chick peas, not receive the full therapeutic benefit of
green tea, pork liver and beef liver. the medication. The Joint Commission on
Alcoholic beverages may increase the the Accreditation of Healthcare
central nervous system depressant effects Organizations (JCAHO) requires that a
of medications such as benzodiazepines, patient’s medication profile include
antihistamines,antidepressants, potential drug-food interactions, that the
antipsychotic, muscle relaxants, narcotics pharmacist call the prescriber whenever
or any drug with sedative actions.3 the potential for a medication-food
An example of a food potentiating the interaction exists and document the
effect of a medication is coffee, as caffeine communication and follow-up action on
has additive effects on theophylline. It has the prescription or order form, and that
been reported that caffeine increased patients be given instructions and
serum theophylline levels by 20%–30% counseling regarding the potential for
and increased the half-life of theophylline drug-food interactions before their hospital
by decreasing clearance. Patients may discharge. Elderly patients may be at a
complain of nervousness, tremor or greater risk for drug-food interactions
insomnia. Caffeine has some because they typically consume more
bronchodilatory effects, which may medications for their chronic medical
enhance the effects of theophylline. A conditions. A study of drug-nutrient
lower dosage of theophylline may be interactions in long-term care facilities
necessary for those patients who consume found a significant relationship between
excessive quantities of coffee (more than 6 the number of medications a resident
cups daily). consumed and the number of drug-nutrient
interactions for which a resident was at
ROLE OF PHARMACIST IN risk.13
PREVENTION OF DRUG-FOOD
INTERACTIONS Counseling and Guidance about Drug-
Food Interactions
Pharmacists in every practice setting need
to be vigilant in monitoring for potential The following information can be given to
drug-food interactions and advising the patients while dispensing the
patients regarding foods or beverages to medicine.13-14
avoid when taking certain medications. It
is imperative for pharmacists to keep up- • Read the prescription label on the
to-date on potential drug-food interactions container. If you do not understand
of medications, especially today’s new something or think you need more
drugs, so that they may counsel properly. information, ask your physician or
In providing drug information to patients, pharmacist.
pharmacists often discuss potential side
effects and how the medication should be • Read directions, warnings and
taken. It is important to provide interaction precautions printed on all
information to patients on when to take medication labels and package inserts.
their medications in relation to food intake. Even over-the-counter medications can
Consequences of drug-food interactions cause problems.
may include delayed, decreased or
enhanced absorption of the drug. Food • Take medication with a full glass of
may also affect the bioavailability, water.
metabolism and excretion of certain
medications. The patient may experience
Asian Journal of Pharmaceutical and Clinical Research
Vol.2 Issue 4, October.-December. 2009
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