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List Drug Food Interactions
List Drug Food Interactions
Drug-Food Interactions
he use of computerized drug interaction screens, built dramatic response to the new therapy. As the patients depres-
into community pharmacy computer systems and used sion diminished, his appetite returned, and on one occasion he
by many on-line, point-of-sale prescription claim ad- consumed a substantial quantity of chocolate (known to con-
judication systems, have become an important tool for phar- tain some tyramine, but generally considered safe for con-
macists in preventing negative outcomes associated with drug- sumption in moderation in tyramine-free diets). Two hours
drug interactions. Food-drug interactions are more challenging later, the patient presented to the Emergency Department
(since food consumption is not documented on patient pro- complaining of a severe headache. A diagnosis of hypertensive
files), but often pose equally substantial risk of negative crisis was made and treatment with nitroprusside was begun.
outcome. Consider this brief case-in-point adapted from the Unfortunately, the patient suffered a stroke and died within 20
records of the University of Wisconsin Hospital and Clinics minutes of treatment initiation.
(this describes an actual case, but many details have been Despite the appropriate education and warnings provided
modified). by the patients physician and pharmacist, this food-drug
Case: A forty-nine year old male patient with a history of interaction caused the death of a patient. In this issue, Sarah
severe depression is placed on a monoamine oxidase inhibitor Bland provides a thorough reference tool that can be referred
(MAOI) after failing on treatment with tricyclic antidepres- to as patients are counseled on diet considerations that affect
sants and selective serotonin re-uptake inhibitors. The patient their medication therapy. It is critical that pharmacists remain
was warned of possibly severe hypertensive reactions associ- aware of potential food-drug interactions, recognize that they
ated with the consumption of foods high in tyramine (a pressor will not be warned of potential interactions by their standard
amine) while on the MAOI. The patient remained adherent to drug-drug interaction software, and intervene with informa-
a tyramine-free diet for several months, and was showing tion and education when necessary. Lee Vermeulen
The information given and views expressed herein do not necessarily reflect the opinions of PSW, its Board or members.
A reduced rate of absorption may sometimes be useful in should avoid drinking grapefruit juice for two hours before and
reducing the side effects of a drug, as in the case of ibuprofen, four hours after taking drugs in this category. If the drug is in
without reducing bioavailability. an extended-release dosage form, patients should wait until six
The bioavailability of some drugs may be enhanced by hours have passed before drinking grapefruit juice.
food. For example, an acid environment is necessary for the
absorption of ketoconazole. The absorption of griseofulvin is Additional information about drug-food interactions can
increased by fat in a meal. Fenofibrate, mebendazole, be found in these references:
isotretinoin, tamsulosin, carbamazepine and labetalol are ex- 1. Lieber CS. Mechanisms of ethanol-drug-nutrition interactions. J Toxicol
Clin Toxicol 1994;32:631-81.
amples of drugs that will be better absorbed when taken with 2. Bailey DG, Malcom J, Arnold A, Spence JD. Grapefruit juice-drug
food. Improved absorption of a drug may or may not have a interactions. Br J Clin Pharmacol 1988;46:101-10.
significant effect on the drugs efficacy. 3. Walker SE, Shulman KI, Tailor SAN, Gardner D. Tyramine content of
Chemical or pharmacologic interactions occur through a previously restricted foods in monoamine oxidase inhibitor diets. J Clin
Psychopharmacol 1996;16:383-88.
wide variety of mechanisms. A very common interaction is 4. Booth SL, Charnley JM, Sadowski JA, Saltzman E, Bovill EG, Cushman
that between beverage alcohol and drugs that have sedative M. Dietary vitamin K1 and stability of oral anticoagulation: proposal of a diet
effects. The effects of sedative drugs will usually be potenti- with constant vitamin K1 content. Thromb Haemost 1997;77:503-9
5. Bieck PR, Antonin K-H, Schmidt E. Clinical pharmacology of reversible
ated by the consumption of alcohol. Opiates, benzodiazepines monoamine oxidase-A inhibitors. Clin Neuropharmacol 1993;16suppl.2:s34-
and antihistamines are well-known examples of this phenom- s41.
enon. Another alcohol-related interaction is the competitive 6. Williams L, Hill DP, Davis JA, Lowenthal DT. The influence of food on the
absorption and metabolism of drugs: an update. Eur J Drug Metab
inhibition of the enzyme aldehyde dehydrogenase, often called Pharmacokinet 1996;21:201-11.
the Antabuse® reaction. Nausea, vomiting, flushing, dizzi- 7. DArcy PF. Nutrient-drug interactions. Adverse Drug React Toxicol Rev
ness and tachycardia may occur with exposure to alcohol in 1995;14:233-54.
patients taking some cephalosporins, ketoconazole, metron- 8. Ameer B, Weintraub RA. Drug interactions with grapefruit juice. Clin
Pharmacokinet 1997;3:103-21.
idazole and sulfonylureas. In addition, chronic alcohol overuse 9. Fuhr U. Drug interactions with grapefruit juice: extent, probable mecha-
can increase the toxicity of some drugs, as with acetaminophen nism and clinical relevance, Drug Safety 1998;18:251-72.
and methotrexate, or reduce the drugs efficacy, as with pheny- 10. Livingston MG, Livingston HM. Monoamine oxidase inhibitors: an
update on drug interactions. Drug Safety 1996;14;219-27.
toin. 11. Brown C, Taniguchi G, Yip K. The monoamine oxidase inhibitor-
Components of food may antagonize the desired effect of tyramine interaction. J Clin Pharmacol 1989;29:529-32.
the drug, as in the case of warfarin. Foods which are high in 12. Lippman SB, Nash K. Monoamine oxidase inhibitor update: potential
adverse food and drug interactions. Drug Safety 1990;5:195-204.
vitamin K, or which enhance vitamin K production by intesti- 13. Muller JL, Clauson KA. Pharmaceutical considerations of common herbal
nal microorganisms, can reduce the effectiveness of warfarin medicine. Am J Managed Care 1997;3:1753-70.
in diminishing the bodys supply of vitamin K, which is needed 14. Ernst E. Harmless herbs? A review of the recent literature. Am J Med
to activate clotting factors. Changing to a diet with increased 1998;104:170-8.
consumption of leafy and/or dark green vegetables, such as
spinach and turnip greens, could lessen the degree of antico- Note: The list of drugs on the following pages includes only
agulation made possible by warfarin by supplying additional drugs that have been or are currently on the UW Hospital &
vitamin K. Clinics formulary. The absense of a drug on this list does
Perhaps the most feared food-drug interaction is that be- not necessarily mean that it has no drug-food interactions.
tween monoamine oxidase inhibitors (MAOIs) and the amino
acid tyramine, which is found in a variety of aged, fermented,
overripe or pickled foods and beverages and, to a lesser extent,
chocolate and yeast-containing foods. Tyramine is indirectly
sympathomimetic. When its metabolism is suppressed, as it is
by MAOIs, it can cause a significant release of norepinephrine,
resulting in markedly increased blood pressure, cardiac
arrhythmias, hyperthermia and cerebral hemorrhage.
The interaction between grapefruit juice and a variety of
drugs has been widely reported. It appears that one or more
flavonoids found in grapefruit juice inhibit some of the en-
zymes in the cytochrome P450 system. This results in reduced
metabolism of drugs that are cleared by the same system;
bioavailability may increase by as much as 200%. Patients
DRUG-FOOD INTERACTIONS
DRUG EFFECT NOTE DRUG EFFECT NOTE
Acetaminophen reduced rate of absorption; chronic Azathioprine reduced side effects F
alcohol ingestion increases
hepatotoxicity N* Azithromycin reduced absorption E
Amitriptyline increased sedation with alcohol * Cefamandole disulfiram reaction with alcohol *
Amlodipine grapefruit juice inhibits metabolism Cefixime slows rate of absorption; decreased
slightly * side effects N
Amobarbital increased sedation with alcohol * Cefoperazone disulfiram reaction with alcohol *
Amoxapine increased sedation with alcohol * Cefotetan disulfiram reaction with alcohol *
ACTION KEY: Ctake with or without food, but be consistent; Etake on an empty stomach; Nno specific action necessary, but consistency may be advised;
Ftake with food; *specific action/precaution as in food effects column
Clarithromycin slows rate of absorption; may reduce Dimenhydrinate increased sedation with alcohol *
GI side effects N
Diphenhydramine increased sedation with alcohol *
Clomipramine increased sedation with alcohol;
metabolism reduced by grapefruit juice * Disulfiram alcohol intolerance *
Clonazepam increased sedation with alcohol * Divalproex sodium delayed absorption; reduced side
effects with food; increased sedation
Clonidine increased sedation with alcohol; with alcohol F*
reduces side effects N
Doxepin increased sedation with alcohol *
Clorazepate increased sedation with alcohol *
Doxycycline reduced side effects; reduced
Cocaine alcohol increases cardiac absorption with milk; reduced efficacy
toxicity of cocaine * with alcohol F*
Codeine reduced side effects with food; Doxylamine increased sedation with alcohol *
increased sedation with alcohol *
Dronabinol reduced rate of metabolism with
Conjugated estrogens reduced side effects F alcohol *
Cyclobenzaprine increased sedation with alcohol * Enalapril increased bioavailability with fats and
grapefruit juice C
Cyclosporine may increase or delay absorption; fruit
juice reduces absorption; grapefruit Erythromycin increased/decreased absorption
juice increases AUC C* depending on form; avoid high fat
meals with P.C.E. *
Cyproheptadine increased sedation with alcohol *
Erythromycin/
D-xylose interference with test outcome; fast sulfisoxazole reduced side effects F
overnight & 5 hrs post-test E
Ethinyl estradiol reduced side effects F
Danazol increased absorption C
Ethionamide reduced side effects F
Dantrolene increased sedation with alcohol *
Etidronate reduced absorption E
Delavirdine increased absorption when taken with
acidic juices C Etretinate increased absorption with high-fat
foods C
Demeclocycline reduced absorption E
Felbamate reduced side effects F
Desipramine increased sedation with alcohol *
Felodipine bioavailability markedly increased by
grapefruit juice and fatty meals *
ACTION KEY: Ctake with or without food, but be consistent; Etake on an empty stomach; Nno specific action necessary, but consistency may be advised;
Ftake with food; *specific action/precaution as in food effects column
ACTION KEY: Ctake with or without food, but be consistent; Etake on an empty stomach; Nno specific action necessary, but consistency may be advised;
Ftake with food; *specific action/precaution as in food effects column
Methenamine foods which alkalize urine may reduce Nicotine polacrilex reduced absorption in presence of
efficacy * acidic substances such as coffee or cola *
Methocarbamol increased sedation with alcohol * Nifedipine capsules reduces rate of absorption reduced
side effects; grapefruit juice increases
Methohexital increased sedation with alcohol * AUC C*
Methotrexate reduced absorption with food; increased Nifedipine ERT depends on brand
hepatotoxicity with chronic alcohol use E * *Adalat CC *delayed absorption *E
**Procardia XL **minimal effects; **C
Methoxsalen increased absorption; reduced side grapefruit juice increases AUC *
effects F
Nisoldipine reduced rate of absorption grapefruit
Methylprednisolone reduced side effects F juice inhibits metabolism *
Methysergide reduced side effects F Nitrendipine grapefruit juice greatly enhances
bioavailability *
Metoclopramide take 30 minutes ac for best effect;
increases rate of absorption of alcohol * Nitrofurantoin increased absorption with food F*
Metoprolol increased absorption C Norfloxacin dairy products decrease absorption *
Metronidazole reduced side effects with food; Nortriptyline increased sedation with alcohol *
disulfiram reaction with alcohol F*
Olanzapine increased sedation and orthostatic
Mexiletine reduced side effects; slows rate of hypotension with alcohol *
absorption; reduces rate of caffeine
clearance F Olsalazine increased efficiency of drug F
Midazolam increased sedation with alcohol; Omeprazole delayed absorption E
bioavailability increased by grapefruit
juice * Ondansetron increased absorption N
ACTION KEY: Ctake with or without food, but be consistent; Etake on an empty stomach; Nno specific action necessary, but consistency may be advised;
Ftake with food; *specific action/precaution as in food effects column
ACTION KEY: Ctake with or without food, but be consistent; Etake on an empty stomach; Nno specific action necessary, but consistency may be advised;
Ftake with food; *specific action/precaution as in food effects column
ACTION KEY: Ctake with or without food, but be consistent; Etake on an empty stomach; Nno specific action necessary, but consistency may be advised;
Ftake with food; *specific action/precaution as in food effects column