Grapefruit Juice (GFJ) – Drug Interactions:

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ª  Grape fruit juice (GFJ) can interact with more than 85 medications including Simvastain, Lovastatin, Amiodarone, Dronedarone, Erythromycin, Domperidone, Nilotinib, Sunitinib, Cyclosporine, Tacrolimus, Sirolimus, Everolimus, Ketamine, Alfentanil, Fentanyl, Oxycodone, Methadone, Terfenadine, Diazepam, Midazolam, Triazolam, Felodipine, Manidipine, Nisoldipine, Ethinylestradiol, Fluvoxamine, Sertraline, Fluoxetine,Trazodone, etc.

ª  GFJ contains Furanocoumarins which could inhibit the body's CYP3A4 metabolizing enzyme resulting in to toxic drug levels.

ª  GFJ consumption could elevate the risk of Rhabdomyolysis in patients taking lipid regulating drugs like Simvastatin or Lovastatin.

ª  The drugs like Dronedarone, Amiodarone, Erythromycin, Domperidone, Nilotinib or Sunitinib can interact with GFJ resulting in to increased risk of Torsades de pointes.

ª  The risk of Nephrotoxicity might be raised by the consumption of GFJ along with drugs like Cyclosporine, Tacrolimus, Sirolimus or Everolimus.

ª   The patients consuming GFJ along with the drugs such as Ketamine, Alfentanil, Fentanyl or Oxycodone could be at the increased risk of Respiratory Depression.

ª   Patients should ask a pharmacist or other health care provider if they can drink grapefruit and other juices with prescribed medications.

ª  The adverse drug interactions of GFJ could be minimized by Pharmacists and other health professionals who properly screen and educate patients about potential fruit juice interactions.

ª  Any problems can be solved by avoiding grapefruit juice (GFJ).

Supplement – Drug Interactions (Part 4):

Omega -3 Fatty Acids – Drug Interactions:

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vOral contraceptives might interfere with the triglyceride-lowering effects of Omega-3 fatty acid supplements.

vOmega-3 fatty acids can increase the effects of Antihypertensives and may lower blood pressure too much.

vOrlistat might prevent the absorption of Omega-3 Fatty Acids.

vThe risk of bleeding might be elevated by concomitant use of Omega-3 fatty acids and Anticoagulant or Antiplatelet drugs.

vOmega-3 fatty acid supplements may increase fasting blood sugar levels and interfere with the effectiveness of Antidiabetics.

vConsumers should consult with the doctor, pharmacist, or dietitian to know about the safety of a supplement or herb.

vDietary supplements are not drugs and are not intended to treat, diagnose, mitigate, prevent, or cure diseases.

Supplement – Drug Interactions (Part 3):

Herb – Drug Interactions:

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Ø The herbs like Alfalfa, Aloe vera, Cinnamon, Ephedra, Evening primrose, Garlic, Gingko, Ginseng, Green Tea, Kava, Licorice and St.John’s Wort can interact with various medicines.

Ø The effectiveness of Warfarin, Oral contraceptives and Immunosuppressants might be decreased by the co administration of Alfalfa.

Ø Aloe gel can increase the risk of hypoglycemia when used along with antidiabetic drugs.

Ø Cinnamon can increase the risk of hepatotoxicity while administering along with drugs like Acetaminophen, Amiodarone, Carbamazepine, Isoniazid, Methotrexate, Methyldopa, Fluconazole, Itraconazole, Erythromycin, Phenytoin, Lovastatin, Pravastatin, Simvastatin, and many others. Cinnamon can also increase the risk of hypoglycemia when it is administered with antidiabetic drugs.

Ø Ephedra can increase the risk of cardiac side effects of QT prolonging drugs. The heart rate and blood pressure might be elevated by the concomitant use of Ephedra and Methylxanthines, Stimulant drugs, Ergot alkaloids or MAO inhibitors.

Ø The risk of bleeding is increased by taking Evening Primrose oil along with Anticoagulant / Antiplatelet drugs. Taking evening primrose oil with phenothiazines might increase the risk of having a seizure in some people.

Ø Garlic may decrease the effectiveness of Isoniazid (INH), Antivirals, Oral Contraceptives and CYP3A4 Substrates.

Ø Ginger may increase the chances of bruising and bleeding when it is concomitantly used with Anticoagulant or Antiplatelet drugs. Ginger might decrease the blood sugar and hence it may increase the risk of hypoglycemia by interacting with antidiabetics. The risk of hypotension may be elevated by the combination of Ginger and CCBs.

Ø Gingko might change the effectiveness of Antidiabetics. The risk of bleeding might be increased by the concomitant use of Gingko and Anticoagulant or Antiplatelet drugs.

Ø The risk of hypoglycemia might be increased by the combined use of Ginseng and antidiabetics. Ginseng may increase the risk of bleeding when it is co administered with Anticoagulant / Antiplatelet drugs.

Ø Green Tea might increase the chances of bruising and bleeding when it is used along with Anticoagulant or Antiplatelet drugs. The side effects of caffeine might increased by the concomitant use of Green Tea and Oral Contraceptives or Quinolone antibiotics.

Ø Kava might decrease metabolism of substrates of CYP1A2, CYP2C19, CYP2C9 and CYP3A4.

Ø Licorice might increase the metabolism of warfarin and decrease its effectiveness leading to increased risk of clotting. The risk of hypokalemia might be increased by the combination of Licorice and Digoxin, Furosemide, Thiazides or Ethacrynic acid.

Ø Senna may increase the risk of hypokalemia when it is used along with Digoxin or Diuretics.

Ø St. John's wort might decrease the effectiveness of substrates of CYP2C19, CYP3A4 and P-Glycoprotein.

Ø Yohimbe might interact with Clonidine, Guanabenz and Antihypertensives and reduce their effectiveness.

Ø Consumers should consult with the doctor, pharmacist, or dietitian to know about the safety of a supplement or herb.

Ø Dietary supplements are not drugs and are not intended to treat, diagnose, mitigate, prevent, or cure diseases.

Supplement – Drug Interactions (Part 2):

Mineral – Drug Interactions:

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§  Minerals are one of the common types of dietary supplements and some of them can interact with prescription or OTC medicines and decrease the therapeutic efficacy or increase the toxicity of medicines.

§  The macro minerals like Calcium, Potassium, Magnesium and micro minerals such as Chromium, Iron, Selenium and Zinc are involved in some drug interactions.

§  Calcium may reduce the absorption of certain Antibiotics (Tetracyclines and Fluoroquinolones), Levothyroxine and Bisphosphonates leading to reduced therapeutic efficacy.

§  The risk of hyperkalemia might be elevated by the concomitant use of Potassium supplements and other drugs such as ACEIs / ARBs, Potassium sparing Diuretics, Digoxin and Indomethacin.

§  Magnesium supplements can decrease the absorption of oral Bisphosphonates, Tetracyclines and Fluoroquinolones. Magnesium can increase the risk of muscle related side effects of Aminoglycosides and Muscle relaxants.

§  Concomitant use of Chromium and Insulin might increase the risk of hypoglycemia. Chromium may reduce the absorption of levothyroxine.

§  Iron supplements can decrease the absorption of Levodopa, oral Bisphosphonates, Fluoroquinolones and Tetracyclines.

§  Taking Selenium along with Anticoagulants or Antiplatelets might increase the chances of bruising and bleeding. The effectiveness of Statins and Niacin might be decreased by Selenium.

§  Zinc dietary supplements can reduce absorption of Tetracyclines, Fluoroquinolones and Penicillamine.

§  Consumers should consult with the doctor, pharmacist or dietitian to know about the safety of a supplement or herb.

§  Dietary supplements are not drugs and are not intended to treat, diagnose, mitigate, prevent, or cure diseases.

Supplement – Drug Interactions (Part 1):

Vitamin – Drug Interactions:

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©  Dietary supplements are not drugs and are not intended to treat, diagnose, mitigate, prevent, or cure diseases.

©  Vitamins are one of the common types of dietary supplements and some of them can interact with prescription or OTC medicines.

©  The interaction between vitamins and drugs may result into decreased therapeutic efficacy or increased toxicity of medicines.

©  Vitamins such as B3, B6, Folic acid, C, A, E and K can interact with some of the medicines which may lead to unwanted effects.

©  Vitamin B3 may interact with drugs such as Antidiabetics, Statins, Antigout drugs and Alcohol.

©  The effects of Phenytoin, Levodopa and Cycloserine might be altered by the concomitant use of Vitamin B6.

©  Folic acid may interrupt the effects of Methotrexate and Antiepileptics.

©  Chemotherapy or Radiation therapy might be disturbed by the coadministration of Vitamin C.

©  Hypervitaminosis A may occur due to concomitant use of Vitamin A and Retinoids (Isotretinoin or Acitretin).

©  Vitamin E can interact with Anticoagulants / Antiplatelets, Chemotherapy / Radiation therapy or Statins / Niacin.

©  Vitamin K can oppose the anticoagulant activity of Warfarin.

©  Consumers should consult with the doctor, pharmacist, or dietitian to know about the safety of a supplement or herb.

Drug – Nutrient Interactions:

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vA Drug - Nutrient interaction occurs when a drug causes Malabsorption, Depletion or Retention of a nutrient.

vDrug - Nutrient interaction results in to either deficiency or toxicity of nutrients.

vThe absorption of vitamins and minerals is lowered by the use of laxatives.

vBile Acid Sequestrants such as Cholestyramine and Colestipol reduce the absorption of fat-soluble vitamins A, D, E, and K due to removal of bile acids.

vOral Contraceptives can lower the levels of vitamin B6 and folate in the body.

vDiuretics can (Furosemide, Hydrochlorothiazide ) increase the excretion of minerals through urine.

vThe levels of micronutrients like Vitamins and Minerals are affected by certain medications.

DRUG – VITAMINS Interactions

vThe drugs like Oral contraceptives, Isoniazid, Hydralazine and Penicillamine reduce the level of Vitamin B6 (Pyridoxine).

vThe absorption of Vitamin B12 may be affected by the drugs such as Colchicine, Cimetidine, Famotidine and Nizatidine.

vThe drugs like Methotrexate and Barbiturates may cause malabsorption of Folate.

vThe level of Vitamin C could be reduced by Salicylates and Tetracyclines.

vThe Retinoids (Isotretinoin and Acitretin) interact with Vitamin A (Supplement) and increase the risk of toxicity (Nausea, Vomiting, Dizziness, Blurred vision, Poor muscle coordination).

vThe absorption of vitamin A might be decreased by Neomycin.

vBile Acid Sequestrants such as Cholestyramine and Colestipol reduce the absorption of fat-soluble vitamins A, D, E, and K due to removal of bile acids.

vDicumarol inhibits hypoprothrombin activity of Vitamin K.

DRUG – MINERALS Interactions

vThe serum sodium levels could be decreased by drugs such as Diuretics (Thiazides and loop), ACEIs, Li, TCAs, SSRIs, MAOIs, Opioids, Sulfonylureas, Clofibrate, Antineoplastic agents (Cisplatin), Vasopressin and Oxytocin.

vThe drugs like NSAIDs, Estrogens, Corticosteroids and Antacids with NaHCO3 may increase the risk of sodium retention.

vThe risk of hypokalemia may be increased by the drugs like Diuretics (Thiazides and loop), Amphotericin B, Bronchodilators (Terbutaline, Albuterol), Aminoglycosides (Gentamycin, Tobramycin), Corticosteroids, Digoxin, Laxatives, Li, Ethanol and Aspirin.

vThe drugs such as Potassium- sparing diuretics (Triamterene, Amiloride, Spiranolactone), Beta blockers (Atenolol, Betaxolol, Labetalol), ACEIs, ARBs and NSAIDs may increase the risk of hyperkalemia.

vHypocalcemia might be induced by drugs such as Loop diuretics, Triamterene, Aminoglycosides, Corticosteroids, Indomethacin, Thyroid hormones and Aluminium containing antacids due to increased calcium elimination.

vMalabsorption of calcium could be induced by drugs like Bile acid sequestrants (Cholestyramine, Colestipol), Corticosteroids (Prednisone), Antibiotics (Minocycline, Erythromycin, Neomycin) and Sulfonamides.

vThe drugs such as NSAIDs, Estrogens, Corticosteroids and Antacids with NaHCO3 may increase the risk of Hypercalcemia by inducing calcium retention.

vThe elimination of phosphorous and the risk of hypophosphatemia might be increased by drugs such as Antacids, Albuterol, Indomethacin, Cisplatin and Sucralfate.

vThe risk of hypomagnesemia may be elevated by the administration of drugs like Diuretics (Loop and thiazides), Albuterol, Amphotericin B, Cyclosporine, INH, Corticosteroids, Digoxin, Oral contraceptives and Ethanol.

vColchicine and overuse of laxatives may produce malabsorption of Magnesium.

vThe risk of hypermagnesemia may be increased by the drugs such as Laxatives (Epsom salts, Aluminium magnesia), Potassium sparing diuretics and Estrogens.

vThe serum levels of Iron might be decreased by drugs like Aspirin, NSAIDs, Deferoxamine and Stanozolol.

vThe drugs such as MgOH containing antacids, Cholestyramine, H2 blockers, Tetracyclines, neomycin, Penicillamine and Zinc may induce malabsorption of Iron.

vOral contraceptives may induce the retention of Iron.

v The serum levels of copper might be decreased by the administration of Penicillamine, Zidovudine, Allopurinol or Valproic acid.

vMalabsorption of Copper might be induced by drugs such as Zinc salts, H2 blockers, ACEIs and Ciprofloxacin.

vOral contraceptives may increase the risk of retention of copper.

vThe serum levels of Zinc might be decreased by drugs like Diuretics (Thiazides and loop), ACEIs, Penicillamine, Zidovudine, Tetracycline, Corticosteroids, Aspirin, Ethanol and Oral contraceptives.

vCholestyramine may induce the malabsorption of Zinc.

vThe drugs like Estrogens, Medroxyprogesterone and Methyltestosterone may increase the risk of retention of Zinc.

vGrowing children, Pregnant women, Older adults, Persons on a poor diet, Persons with serious health problems, , Persons taking two or more medications at the same time, Persons using prescription and over-the counter medications together, Persons not following medication directions, Persons taking medications for a long periods of time and Persons who drink alcohol or smoke excessively are all at more risk of developing Drug-Nutrient interactions.

Food – Drug Interactions:

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•        A Food - Drug interaction occurs when a food interferes with the effects of a drug in the body.

•        The content of certain foods interact with some drugs and produce alterations in the Pharmacokinetic (Absorption, Distribution, Metabolism and Elimination) and Pharmacodynamic (Physiologic actions) effects of the drugs.

•        Tyramine rich foods (Aged Cheese) may induce Life-threatening hypertensive reaction by interacting with Non-selective MAOIs (tranylcypromine, phenelzine etc.) or MAO-B Inhibitor (Higher dose of Selegeline). Patients taking any of the non-selective MAOIs should not eat foods containing substantial amounts of tyramine.

•        Dairy Products (Milk) reduce the absorption and therapeutic efficacy of Fluoroquinolones (Ciprofloxacin, Norfloxacin), Tetracyclines and Bisphosphonates (Alendronate, Risedronate, and Ibandronate).

•        Vitamin K Rich Foods (Kale, Collards, Spinach, Turnip greens, Mustard greens, Beet greens, Dandelion greens, Brussels sprouts and Broccoli) may interact with Warfarin and increase the risk of clot formation. Suddenly increasing or decreasing intake of Vitamin K rich foods can alter the effectiveness of the warfarin. So eat greens in consistent amounts. 

•        Potassium Rich Foods may interact with ACEIs (Lisinopril, etc), ARBs (Losartan, etc), Direct Renin Inhibitors (Aliskiren) or Potassium sparing Diuretics (Spiranolactone, etc) and increase the risk of Hyperkalemia.

•        Fiber Rich Foods may interact with Digoxin, Amoxicillin, Levothyroxine or TCAs (Doxepin and Desipramine) and delay their absorption. Avoid ingesting high-fiber foods concomitantly.  

•        Protein Rich Foods may increase the bioavailability of Propranolol.

•        High Fat Meals may elevate the plasma levels of Griseofulvin. Patients should be instructed to take griseofulvin after a high-fat content meal.

•        Fruit juices like Grapefruit juice (GFJ), Apple juice or Orange juice may reduce the therapeutic efficacy of Fexofenadine.

•         Grapefruit juice (GFJ) may interact with CYP3A4 substrates such as Simvastatin, Amiodarone, Erythromycin, Apixaban, etc. and increase the risk of their toxic effects.

•        Seville orange juice may interact with CYP3A4 substrates like Colchicine, etc. and increase the risk of toxic effects.

•        Orange juice may interact with drugs like Fexofenadine, Atenolol or Fluoroquinolones and reduce their therapeutic efficacy.

•        Apple juice may reduce the therapeutic efficacy of Fexofenadine or Atenolol.

•        Licorice may decrease the effectiveness of Antihypertensives such as Amlodipine, Aliskiren, Valsartan, Captopril, Carvedilol, etc. The people with high blood pressure, heart failure, pulmonary hypertension or kidney disease should avoid or limit the consumption of licorice.

•        Fish (Omega-3 fatty acids) may increase the risk of Bleeding by interacting with drugs like Anticoagulant / Antiplatelet drugs (Aspirin, Clopidogrel, Ticlopidine, Dipyridamole, Alteplase, Dalteparin, Enoxaparin, Heparin, warfarin and others). It is recommended to consult the physician when the patients experience any unusual bleeding or bruising, swelling, vomiting, blood in your urine or stools, headache, dizziness, or weakness during treatment with these medications.

•        Pharmacist or physician should determine the clinical relevance of the interactions of drugs with certain foods or beverages and advise patients appropriately.