Food Drug Interactions Makkah Conference

8/2/2019 Food Drug Interactions Makkah Conference

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Drug-food interactions

The aim of this presentation is to highlight the clinicalinteractionsbetween food and prescribeddrugs


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Definition and incidence of food drug

interaction

Examples of effect of food on medications

absorption, metabolism and excretion

Examples of effect of drugs on food

absorption, metabolism and excretion

Strategies to minimize food-drug

interaction

Outlines


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Any time food changes the effects of a drug, the changeis considered a food-drug interaction.

Although some interactions are harmful, others can bebeneficial.

Incidence of food-drug interactions is 62.4%, which maycause various complications in therapy.

52.8% were not aware that the timing of drug intake inrelation to meals may affect treatment.

Jarosz and Wolnicka (2011): Pol. J. Food Nutn Sei., 2011, Vol. 61, No. 3, pp. 211-218

Definition


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Clinical problems owing to drug interactions were firstrecognized in the early 1960s.

Hypertensive crises were reported in several patients treated

for depression with monoamine oxidase (MAO) inhibitors,after they had eaten certain cheeses (the amino acid tyramine).

Tyramine is indirect sympathomimetic, it can cause a

significant release of norepinephrine.

beer, avocados ,some processed meats, aged, fermented, overripe or pickled foods,

chocolate and yeast-containing foods

F. Sjoqvist & Y. Bo ttiger (2010). Historical perspectives: drug interactionsit all began with cheese.

Journal of InternalMedicine. 268; 512515

Historical Perspectives


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Clinical problems owing to drug interactions were firstrecognized in the early 1960s.

Hypertensive crises were reported in several patients treated

for depression with monoamine oxidase (MAO) inhibitors,after they had eaten certain cheeses (the amino acid tyramine).

Tyramine is indirect sympathomimetic, it can cause a

significant release of norepinephrine.

beer, avocados ,some processed meats, aged, fermented, overripe or pickled foods,

chocolate and yeast-containing foods

F. Sjoqvist & Y. Bo ttiger (2010). Historical perspectives: drug interactionsit all began with cheese.

Journal of InternalMedicine. 268; 512515

Historical Perspectives


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Patient with chronic disease

Elderly

Fetus

Infant

Pregnant woman

Malnourished patient

Allergies or intolerances

Patients at Risk for Food-Nutrient

Interactions


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Figure 4. A working model of drug nutrient interactions.J Acad Nutr Diet. 2012;112:506-517.


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Food-Drug interactions falls into the following categories:

Food-Drug Interactions

1. Drugs that alter food intake

reducing appetite, or increasing appetite leading toweight gain

2- Food that alter drug Pharmacokinetic

Absorption, Metabolism and Excretion of Nutrients,and vice versa


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Nutrients

Absorption

NutrientsMetabolism

Nutrients

Excretion

Drugs

Drugs

Absorption

DrugsMetabolism

Drugs

Excretion

Nutrients

Drugs affecting food intake

Interactions


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Sites of food-drug interactions


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Food changes gastric motility, pH, and provides substances fordrug and nutrient chelation and adsorption.

An acid environment is necessary for ketoconazole absorption.

Vitamin C in the citrus juice increases the absorption of iron.

Increased amounts of stomach acid results in the destruction of

penicillin G, ampicillin and dicloxacillin.

The absorption of griseofulvin is increased by fat meal.

Bland, SE (1998): Drug-Food InteractionsJournal of the Pharmacy Society of Wisconsin

EFFECT OF FOOD/NUTRIENTS ONMEDICATION ABSORPTION


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Calcium or iron components of some foods make complexes

with drugs e.g. tetracycline, doxycycline, sodium fluoride and

ciprofloxacin, levofloxacin and interfere with absorption,.

Fenofibrate, mebendazole, isotretinoin, tamsulosin, labetalol

and carbamazepine are examples of drugs that will be better

absorbed when taken with food.

The absorption of alendronate is impaired by food, calcium,

orange juice and coffee.

Absorption of ciprofloxacin reduced by concomitant ingestion

of the GFJ.

Food-Drug Interactions


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High-protein, low carbohydrate diets induce the mixed-

function oxidase system (theophylline).

Indoles in vegetables, such as cabbage and Brussels sprouts,

and chemicals in charcoal-broiled meats, smoked and

preserved meats induce the mixed-function oxidase system.

On the other hand, Grapefruit inhibit CYP450 isoenzymes

1A2 and 3A4.

EFFECT OF FOOD/NUTRIENTS ONMEDICATION METABOLISM


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GFJ inhibit the intestinal CYP 3A4 and increase the oral

bioavailability of Felodipine, midazolam, cyclosporine,

psychotropics by as much as 200%.

Grapefruit juice inhibit the P-gp activity, modifying the

disposition of drugs that are P-gp substrates such as talinolol,

and enhances CoQ10 absorption (5 folds).

GFJ inhibits organic anion-transporting polypeptide

(OATP), reduce the oral bioavailability of the OATP

substrate fexofenadine Diaconu CH; Cuciureanu M; Vlase L; Cuciureanu R (2011). Food-drug interactions:

grapefruit juice. journal Info rmation

Grape Fruit


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At high urinary pH values, weakly acidic drugs largely exist asionized molecules that cannot be reabsorbed into blood and are

lost in the urine.

Alkaline urine causes the salicylic acid to be excreted.

Patients on low sodium diets will reabsorb more lithium along

with sodium; patients on high sodium diets will excrete

more lithium and need higher doses

EFFECT OF FOOD/NUTRIENTS ONMEDICATION EXCRETION


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Use of antiulcer drugs, decrease the absorption of vitaminB12, thiamin, calcium, magnesium, zinc, and iron.

Potassium chloride lowers the pH in the ileum, impairing

vitamin B12 absorption.

Calcium carbonate increases the rate of absorption of folic acid

due to an increased dissolution rate.

Aluminum antacids can precipitate bile acids, leading to

decreased absorption of vitamin A.

EFFECT OF MEDICATION ONFOOD/NUTRIENT ABSORPTION


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Anticonvulsants, phenobarbital, and phenytoin increase the

metabolism of folic acid and vitamins D and K.

The antituberculosis drug, isoniazid, inhibits the conversion ofB6 to its active form.

EFFECT OF MEDICATION ONFOOD/NUTRIENT METABOLISM


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Laxatives increased excretion of nutrients. Malabsorption ofnutrients by the increased gastric motility can lead to

significant metabolic imbalances.

Loop diuretics increase the excretion of Na, K, Cl, Mg, andCa. Persons using diuretics are frequently instructed to take the

medication with a banana or orange juice.

EFFECT OF MEDICATION ONFOOD/NUTRIENT EXCRETION


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Examples of Drug Groups and Possible Food

Interactions


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Lovastatin should be taken with food to enhance GITabsorption and bioavailability.

Rosuvastatin absorption was significantly decreased with food

(given on an empty stomach)

High fiber diets may lower the efficacy of Simvastatin,

Ezetimibe, pravastatin and fluvastatin.

Oman Medical Journal (2011) Vol. 26, No. 2: 77-83

Cholesterol-Lowering Agent


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Leafy and/or dark green vegetables, such as broccoli, Brussels

sprouts, kale, parsley, spinach, turnip greens and charbroiled

food decrease the anticoagulant activity of warfarin by

supplying additional vitamin K.

There is a possible interaction between warfarin and a high

protein diet. Dietary protein intake decrease in international

normalized ratio (INRs).


Warfarin


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Warfarin


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The opposite can happen with vitamin E, onions, and garlicbecause they all produce effects that are similar to those of

warfarin.

Warfarin

The combination of warfarin administration and cranberry

juice ingestion is associated with an elevated INR as cranberry

juice may inhibit the activity of CYP2C9.

Oman Medical Journal (2011) Vol. 26, No. 2: 77-83 American Pharmacists Association


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Propranolol serum levels increased if taken with diet rich protein

Smoking decrease plasma levels of by increasing its metabolism.

Orange juice (Hesperidin), decreased absorption of celiprolol.

ACEs inhibitors absorption increased when taken on empty

stomach.

While GFJ increases the bioavailability of felodipine

Licorice extract (glycyrrhizin and glycyrrhetinic acid) causes

sodium retention, interfere with antihypertensive agents.

Bland, SE (1998): Drug-Food InteractionsJournal of the Pharmacy Society of Wisconsin

Antihypertensive Drugs


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Food slows the body absorption of acetaminophen

NSAIDs like ibuprofen, naproxen, ketoprofen can cause

stomach irritation and thus they should be taken with food or

milk.

The Cmax of ibuprofen increased after Coca-Cola drinking,

indicating increased absorption of ibuprofen.

Food intake did not affect the absorption of oral Diclofenac.


Analgesics and Antipyretics


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Fexofenadine, loratadine, rupatadine, cimetidine cetirizine,

are all antihistamines.

It is best to take prescription antihistamines on an emptystomach to increase their effectiveness.


Antihistamines


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High-fat meals increase the amount of theophylline in the

body, while high carbohydrate meals may decrease it.

Caffeine (chocolate, colas, coffee, and tea) contains xanthine

that increases the risk of drug toxicity when taken with

xanthine derivative, theophylline.

GFJ increases the bioavailability of theophylline.


Bronchiodilators


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Isoniazid is associated with tyramine and histamine

interactions as it inhibits monoamine oxidase and histaminase.

Food greatly decreases isoniazid bioavailability.

Oleanolic acid has antimycobacterial activity against the

Mycobacterium tuberculosis, when administered with

isoniazid, it exerts synergistic effect.

High fat meals decrease the serum concentration of

cycloserine, a bacteriostatic anti-tubercular drug and results in

incomplete eradication of bacteria.


Antitubercular Drugs


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Glimepiride administered with breakfast or the first main mealof the day. (absence of food interaction).

Immediate release glipizide taken 30 minutes before meals.

However, extended release tablets taken with breakfast.

Acarbose, is taken immediately at the start of each meal

because it delays the carbohydrate absorption by inhibiting the

enzyme alpha-glucosidase.


Antidiabetics


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Thyroxine better absorbed on empty stomach.

Iron and Ca++ supplements delay absorption of Thyroxin.

Grapefruit juice delay the absorption of levothyroxine, but it

seems to have only a minor effect on its bioavailability.


Thyroxine


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Mercaptopurine is inactivated by xanthine oxidase (XO),

Cows milk contains a high level of XO, So, concurrent

intake reduces bioavailability of mercaptopurine.

Sesame seeds, negatively interferes with tamoxifen in

inducing regression of established tumor size but beneficially

interacts with tamoxifen on bone in ovariectomized athymic

mice.

Immunomodulatory diet containing glutamine and n-3 fatty

acids is useful adjuncts with antitumor treatment.


Antitumor Drugs


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Medications achieve their intended effects

Improved compliance with medications

Less need for additional medication or higher dosages

Fewer caloric or nutrient supplements are required

Adverse side effects are avoided

Benefits of Minimizing Food DrugInteractions


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The clinician should become more proactive in anticipating

potential food drug interactions.

Educating patients, physicians, dieticians and nurses on theimpact of food on the effects of drugs is necessary to avoid

pharmacotherapy complications.

Medication orders are reviewed for existing or potentialinteractions between the medication ordered and food and

medications the patient is currently taking

Measures to avoid food druginteractions


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Food-drug interactions can produce negative effects in safety

and efficacy of drug therapy, as well in the nutritional status

of the patient.

Interactions can be avoided by properly timing the drug intake

with food.

It is suggested that patients should tell their doctors andpharmacists about their food intake and dietary supplements

so that interactions can be avoided.

Conclusion


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Lack of database for hospitalization from food drug

interactions

Lack of researches on food drug interactions

limitation


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Diet has a significant

impact on proper andsafe treatment

Take Home Message


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Miroslaw Jarosz*, Katarzyna Wolnicka Relations Between Oecurrence of

the Risk of Food-Drug Interaetions and Patients' Soeio-Demographic

Characteristics and Selected Nutrition Habits. Pol. J. Food Nutn Sei., 2011,

Vol. 61, No. 3, pp. 211-218


Bland, SE (1998): Drug-Food InteractionsJournal of the Pharmacy Society

of Wisconsin

Diaconu CH; Cuciureanu M; Vlase L; Cuciureanu R (2011). Food-drug

interactions: grapefruit juice. journal Information

J Acad Nutr Diet. 2012;112:506-517. F. Sjoqvist & Y. Bo ttiger (2010). Historical perspectives: drug

interactionsit all began with cheese Journal of InternalMedicine. 268;

512515

References


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Documents

Food Drug Interactions Makkah Conference