Food and Supplements Can Interfere With Medications

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Litchford, PhD, RD, LDN Do you feel confident identifying potential foods or dietary supplements that

1 Nutrition Connection 1 HOUR CE CBDM Approved Food and Supplements Can Interfere With Medications by Mary D. Litchford, PhD, RD, LDN Do you feel confident identifying potential foods or dietary supplements that might interact with medications? Is this part of your quarterly review or do you hope someone else will note the potential food, dietary supplement, and medication interactions? Continued on page 24 23

2 Continued from previous page Visit ANFP Online For more resources on nutrition and MNT including Master Track booklets, reference books, and online courses visit Do you know which residents take vitamin and mineral and herbal supplements? Do you know which residents consume beer, wine, or liquor on a daily basis? When do residents usually take medications? Back to Basics: How Medications React in the Body To understand food-dietary supplements-medication interactions, it s important to understand how medications work in the body. There are four stages of medication action for medicines taken by mouth: Stage 1. The medication dissolves into a useable form in the stomach or small intestine. Stage 2. The medication is absorbed into the blood and transported to its site of action. Stage 3. The medication performs the function for which it is taken. Stage 4. The medication is excreted from the body either by the kidney or the liver, or both. While not all medications are taken by mouth, they are all transported to the site of action. Since medications taken by mouth dissolve in the stomach or small intestine, the presence of food, beverages, or dietary supplements may interfere with the action of the medication. Food AND Medication Interactions Components of foods, beverages, and dietary supplements consumed at the same time as medications can interfere with the way medicine is supposed to work. These interactions can occur with both prescription and over-the-counter medications, including dietary supplements and herbal supplements. Risk for food-dietary supplement-medication interactions can be affected by many factors such as: Age Medical history Body composition Nutritional status Number of medications used Residents often take medications right before a meal or with a meal. Some medications are taken with food to prevent stomach irritation. Even if medications are given between meals, residents may take them with food provided by staff or families. While some of the foods associated with medication interactions are found on the menu, many are brought in by well-meaning friends and family. Common consequences of food-dietary supplement-medication interactions include: Delayed action of the drug Decreased effectiveness of the drug Enhanced absorption of the drug Increased excretion of the drug Faster metabolism of the drug Impaired nutrient utilization Taking Action Make a commitment to identify residents who might experience food-dietary supplement-medication interactions. All medications, dietary supplements, and routine alcohol intake should be noted on the physician orders. Identify residents who consume alcohol on a daily basis. Table 1 summarizes examples of common medication interactions with food and beverages. Dietary Supplements and Medication Interactions Identify residents who take dietary and herbal supplements daily. Many residents take a multiple vitamin and mineral supplement daily that provides the RDA for these nutrients. These products are rarely of concern. It is the high dose single nutrient supplements and herbal products that may interact with medications. Table 2 summarizes common interactions between dietary supplements and medications. Pearls for Practice Identifying and avoiding food, dietary supplement and medication interactions take an ongoing team effort. Educate families and frequent visitors about potential food-dietary supplementmedication interactions. Work collaboratively with the RD, physician, pharmacist, and families to ensure that residents are receiving quality care. j Mary Litchford, PhD, RD, LDN is a nationally-recognized speaker and the author of various articles and books, including Common Denominators of Declining Nutritional Status. 24 Nutrition & Foodservice Edge

3 Table 1: Common Medication Interactions with Food and Beverages Drug Class Analgesic Acetaminophen (Tylenol) Antiarrhythmic Lanoxin (Digoxin) Crystodigin (Digitoxin) Amiodarone Antibiotic Tetracyclines Amoxicillin, Penicillin, Zithromax Erythromycin Nitrofurantoin (Macrobid) Flagyl Anticoagulant Warfarin (Coumadin) Anticonvulsant Phenobarbital Primidone Antifungal Griseofulvin (Fulvicin) Anti-gout Colchicine Antihyperlidemic Atorvastatin (Lipitor) Lovastatin (Mevacor) Simvastatin (Zocor) Ezetimibe/Simvastatin (Vytorin) Antihistamine Diphenhydramine (Benadryl) Chlorpheniramine (Chlor-Trimeton) Antihypertensive Felodipine (Plendil) Nifedipine Anti-inflammatory Naproxen (Naprosyn) Ibuprofen (Motrin) Diuretic Spironolactone (Aldactone) Furosemide (Lasix) Hydrochlorothiazide (HCTZ) Food and Effects Alcohol Increases risk for liver toxicity. High bran fiber and high pectin foods (eg. jellies) may decrease drug absorption. Calcium/Vitamin D supplement may increase drug effect and risk of toxicity. Grapefruit Juice May increase drug absorption. Licorice Increases drug action. Food, dairy; iron supplements Decreases drug absorption. Food Decreases GI distress. Antibiotics decrease the synthesis of Vitamin K in gut. Take antacids, multivitamin supplement, Calcium, Iron, or Zinc supplements or dairy products 2 hours before or after taking medication. Limit caffeine intake. Flagyl Avoid all alcohol. Anticoagulants decrease Vitamin K utilization. Maintain stable intake of Vitamin K-rich foods. Avoid herbal teas that contain coumarin. Alcohol Causes increased drowsiness. Vitamin C Decreases drug effectiveness. Increases the metabolism of Vitamin D. Decreases absorption of folic acid. High-fat meal Increases drug absorption. Decreases absorption of Vitamins A, D, E, K, Vitamin B12, Folic Acid, and Calcium. Alcohol Increases drowsiness. May increase appetite. Food or milk Decreases GI irritation. Alcohol Increases risk for liver and stomach bleeding. Food Decreases GI irritation. Lasix promotes increased excretion of potassium. Increases urinary loss of many minerals. Licorice Decreases drug action. Continued on page 26 25

4 Continued from previous page Drug Class Food and Effects Psychotherapeutic MAO Inhibitors: Isocarboxazid (Marplan) Tranylcypromine (Parnate) Phenelzine (Nardil) Other Psychotherapeutic Buspirone (BuSpar) Sertraline Foods high in Tyramine: Aged cheeses, Chianti wine, pickled herring, Brewer s yeast, fava beans increase risk for hypertensive crisis. Antineoplastic Methotrexate (Trexall) Decreases absorption of Folic Acid, Vitamin B12. Acid Blocker Ranitidine (Zantac) Decreases absorption of Vitamin B12. Cimetidine (Tagamet) Famotidine (Pepcid) Nizatidine (Axid) Laxative FiberCon, Mitrolan Decreases absorption of vitamins and minerals. HIV Saquinavir Immune Suppressing Agents Cyclosporine Tacrolimus Table 2: Common Interactions Between Dietary Supplements and Medications Dietary Supplement St. John s Wort (Hypericum Perforatum) Vitamin E Ginseng Ginkgo Biloba Potential Medication Interactions Reduces the blood level of medications including: Lanoxin (Digoxin) Lovastatin (Mevacor) Sildenafil (Viagra) Increases effectiveness of warfarin (Coumadin) and may cause an increased risk of bleeding. Enhances the anti-clotting effects of heparin, aspirin, and nonsteroidal anti-inflammatory drugs such as ibuprofen, naproxen, and ketoprofen. Combining ginseng with MAO inhibitors such as Nardil or Parnate may cause headache, trouble sleeping, nervousness, and hyperactivity. High doses may decrease the effectiveness of anticonvulsant therapy Tegretol, Equetro or Carbatrol (carbamazepine), and Depakote (valproic acid). References 1. Pronsky, Zm. Food Medication Interactions. 16th Edition. Birchrunville, PA McCabe, B.J., Frankel, E.H., Wolfe, J.J., eds. Handbook of Food-Drug Interactions. CRC Press, Boca Raton, FL Akamine, D., Filho M.K., & Peres, C.M. Drug-nutrient interactions in elderly people. Current Opinion in Clinical Nutrition and Metabolic Care, 10: , Genser, D. Food and drug interaction: Consequences for the nutrition/health status. Annals of Nutrition & Metabolism 52(suppl 1):29-32, McCabe, B.J. Prevention of food-drug interactions with special emphasis on older adults. Current Opinion in Clinical Nutrition and Metabolic Care, 7:21-26, Important Drug and Food Information. NIH Clinical Center. drug_info.html. Accessed 2/12/ Food + Drug Interactions. National Consumers League. avoid-food-drug-interactions. Accessed 2/11/ Nutrition & Foodservice Edge

5 Nutrition Connection Review Questions CE 1 HOUR CBDM Approved Reading Food and Supplements Can Interfere With Medications in this magazine and successfully completing these review questions has been approved for 1 hour of continuing education credit for CDM, CFPPs. The article and questions are also online at No. 364 Please Mark Your Answer 1. What is the first step in the action of a medication taken by mouth? A. Medication dissolves in mouth B. Medication dissolves in stomach or small intestine C. Medication dissolves in the blood 2. Risk factors for food, dietary supplement/medication interactions are: A. Age, medical history, and number of medications used B. Body composition and nutritional status C. All of the above 3. One common consequence of food-dietary supplementmedication interactions is: A. Enhanced absorption of medication B. Increased calcium deposits in joints C. Increased life expectancy 4. Grapefruit juice should be avoided when taking these classifications of medications: A. Antiarrhythmic, antihyperlidemic, antihypertensive B. Antibiotic, anticoagulant, anticonvulsant C. Antifungal, anti-inflammatory, acid blockers 6. Which medication promotes increased excretion of potassium? A. Furosemide B. Ibuprofen C. Lovastatin 7. Which commonly used dietary supplement increases the effectiveness of warfarin? A. St. John s wort B. Ginseng C. Vitamin E Must Complete: Please describe what you learned from this article: What changes will you make at your facility after reading this article? 5. Which medications interfere with Vitamin B12 absorption? A. Antibiotics, anticoagulant, anticonvulsant B. Acid blockers, antineoplastic, antihyperlidemic C. Antihistamine, diuretic, anti-inflammatory Contact Information ANFP Member No. Name Address City State Zip Daytime Phone Address For credit card payment, complete the following: Visa MasterCard Discover Name on Card Card # Expiration Date Signature Billing Address Mail this form with check or money order for $12 to cover processing to: ANFP Professional Development Services Department, 406 Surrey Woods Drive, St. Charles, IL If paying by credit card, you may fax this form to ANFP at: (630) To complete these questions and earn one CE credit online, please visit You will be notified only if you did not receive CE credit. For ANFP Use Only Account # No. 364 Amount Charged Date Entered 27

FOOD/DRUG AND DRUG/NUTRIENT INTERACTIONS: What You Should Know About Your Medications 1

10 FCS8092 FOOD/DRUG AND DRUG/NUTRIENT INTERACTIONS: What You Should Know About Your Medications 1 Linda B. Bobroff, Ashley Lentz, and R. Elaine Turner 2 Introduction Medications, both prescription and