Interactions between Common Foods and Drugs - A Narrative Review

Swapan Banerjee*

Department of Nutrition, Seacom Skills University, Kendradangal - 731236,

Dist.-Birbhum, West Bengal, India.

*Corresponding Author E-mail: sbanerjee90@gmail.com

ABSTRACT:

Common people often knowingly or unknowingly commit mistakes about the simultaneous selection of some foods and daily recommended medicines. A drug or medication prescribed by a doctor should be taken as per the schedule, but consuming a particular food item at the same time may be fatal due to the food-drug interaction. This study reviewed the identified literature for twenty years and discussed the latest knowledge on food and drug interaction. The objective of this review study is to consider the details of the interactions between two essential eatable items and to analyze both sides, good and bad. In the narrative review study where the publications cited from the last twenty years of original research and review articles based on relevant keywords. Potential commonly consumed foods and highly recommended daily medicines as drugs have been considered. The study analyzed that so many foods are having adverse effects on the human body while interacting or reacting with some medication. Foods and drugs are both mandatory, but the concerned patient must select the right foods by a dietitian and the drug based on prescription by a doctor. The knowledge of food and drug interactions is undoubtedly compulsory to avoid health hazards and further complications.

KEYWORDS: Foods selection, food-drug interaction, health hazard, foods safety, diet, nutrition.

INTRODUCTION:

Foods and Drugs selection

Foods are the source of the energy by which living beings can perform all functions inside the body and, as a result, able to do all necessary works. Foods are helpful if sorted and selected rightly. At the same time, foods are harmful while consumed unwisely. Foods have adverse effects while rotten, backdated, improperly cooked, excessive trans-fat or saturated fat-rich, or maybe too much salted and sugar-rich. Some foods are also reactive while a specific drug (as medicine) eaten simultaneously or inappropriately. There is a requirement of proper knowledge of food-drug interactions among dietitians, pharmacists even doctors¹. As per studies, they are the skilled professionals who can alert the adverse effects of that interaction in the body while a particular food and medicine consumed simultaneously.

So it's better to omit anyone either food or that drug or the right alternative. Medicine is the 1^st choice and always have first preference for a typical patient suffering from any disease with the chronic or acute stage. So the priority is given to a doctor who prescribes the drug of choice to cure that respective patient. However, the diet must be incorporated as a secondary therapy by the dietitian under the advice of the concerned doctor. This action is just to predetermine the interaction between the prescribed medicine and particular food.^1,6

Online survey and inclusion of literature:

In this study, the literature survey was conducted through various reviews and original articles by extracting data from April 1999 till March 2019 for twenty years. An electronic search of the literature identified from NCBI (NIH, Pubmed, PMC), Scopus open-access databases by the time frame of three months (Sep 2019 to November 19). Knowingly, inclusions of the articles were based on foods and drug interactions topics published in, and onwards 1997 by the searching keywords' foods-drug interaction', 'foods toxicity, 'diet' and 'medicines,' etc.

Drugs (medicines):

The selection and review of the drugs supported the everyday prescription habits of the doctors/physicians and availability, starting from zonal to global markets. As a priority, medicine comes first for a typical patient except for some issues like obesity. At the same time, the diet recommended for the concerned patient should be taken care of all interactions. In this study, reviews and discussions were done based on the foods, show the adverse effect of the medicines. The literature review pointed out the following consequences due to the adverse impacts while interacting with any particular diet. i) reducing bio-availability of the concerned drug, hence low improper medicinal effect ii) chelation due to contact with food iii) gastric irritation or G.I discomfort including nausea or vomiting and iv) other severe complication^1,2,3.

Foods and Diet:

The study is mainly prioritizing the prescribed medicines, i.e., the drugs, which should be the first choice for the patients. Similarly, the selection of foods are as follows: i) firstly inadequate scientific information or unknowingly uses (ignorance and awareness) ii) General risks from essential or addicted foods (excess coffee or sub-standard wine consumption); iii) bodybuilding or other supplements consumption iv) contamination due to unhygienic condition v) improper cooking ingredients (meal) and interactions with drugs) ^1,3. All of these reactions happened because of incorrect combinations or insufficient knowledge about raw or cooked foods or with its ingredients and prescribed medications. So dietitians or nutritionists must collaborate with the doctors while preparing a diet plan, and the patients who are not under diet counselling should seek the respective doctor's advice to avoid food and drug interactions and their adverse effects.

Pharmacokinetics and Pharmacodynamics:

In the pharmacokinetics, bio-availability of the drug is depending on the dosage, manufacturing quality, and other factors like foods consumed. So the interactions between a particular food and medicine can change both and anyone. Even a drug administered with the right dosage but low bioavailability observed due to reduced rate of absorption and metabolism. If pharmacokinetics of a drug is affected, the pharmacodynamics also gets affected synergistically due to the antagonistic action. That manifests the incomplete and improper function of the recommended medicine because of poor bioavailability^2,3,4.

Multivitamins and Supplements:

Fat-soluble multivitamins (Vitamin - A, D, E, K) and some herbal supplements often cause belching or other gastrointestinal complications if overdose or long term consumption. Coenzyme Q-10 (CoQ10) is present in food supplements widely accepted because of its health benefits mainly among body-builders⁵⁵. It is proven on food-drug interaction issue because it affects intestinal efflux transporter P-glycoprotein⁵. Unknowingly, people do face so many foods and drug interaction issues due to the over usage of herbal or high protein supplements, which are on-demand in the market. Some commercial fruit juices, cola products, even berries also contain reactant that affects drug-metabolizing enzymes^6,17,51.

Grapefruits Juice (GFJ) interaction:

Grapes, pomelo, a kind of orange, and star fruit are having some toxic agents that interfere with drug metabolism enzyme, cytochrome P450 3A4 (CYP3A4). Furanocoumarin, which is present in GFJ, inhibits the CYP3A4 enzymes. The enzyme can interfere with the bioavailability of plenty of drugs, which may affect the nutrition process or vice versa. In this case, enteric-coated tablets may reduce adverse effects due to intestinal level absorption. Studies found that apple or orange juice can interact with aliskiren and fexofenadine ^7,8. Grapefruit juice can also slow down the entire absorption process of the fluoroquinolone derivative group (Ciprofloxacin)⁹.

Antibiotics:

Milk and milk products should not be consumed with antibiotics due to divalent ions. Calcium and magnesium contain the ions that inhibit the absorption of antibiotics and often cause nausea, vomiting. 8. Milk contains casein protein, which decreases the bioavailability of ciprofloxacin^9,10. The patient should avoid any meal after or along with azithromycin because it gets a 43% reduction of bioavailability in vivo 11. Tetracycline also interacts with casein and calcium present in cows or buffalo's milk and form a chelate. Tetracycline is usually recommended 2 hours after or before any major meals to avoid the chelation^11,12,13. The study found that a small quantity of ca²⁺ can affect the metabolism of the concerned drug due to its metal ion¹⁴.

Analgesics and Antipyretics:

The common analgesic and antipyretics are Ibuprofen, Naproxen, Ketoprofen, Acetaminophen. Acetaminophen should be consumed at an empty stomach due to slow absorption if taken with food. Acetaminophen with pectin may delay its bioavailability while co-administered¹⁵. Almost all the non-steroidal anti-inflammatory drugs (NSAIDs) may be the reason G.I discomfort; so recommended with a meal, although excess dairy may be the reason for belching and other abdominal discomforts¹⁶. The patients who consume almost regular analgesics must not be drinking alcohol. Alcoholic patients with daily smoking habits may cause severe cardiovascular and liver disorders due to elevated cholesterol, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) levels, etc.^17,56.

In the fast lifestyles, people often enjoy Coca-Cola or similar cola products. History of drinking Coca-Cola within 2-4 hours of intake of Ibuprofen may cause gastrointestinal issues or poor performance of pain reduction due to the slow absorption of the drug. For this kind of patient, doseand its frequency must be reduced in case the patient does not get rid of cola addiction. Another NSAID, diclofenac potassium, can be recommended as a soft or hard gelatin capsule at average doses by the doctor. There is no such adverse effect due to this drug, along with any kind of food. So diclofenac potassium can be consumed with foods but not an empty stomach. However, this diclofenac sodium and diclofenac potassium often create G.I discomfort if not-gelatinized coated, so any antacid or other proton pump inhibitor must be added simultaneously with these drugs. In general, any NSAID manly diclofenac group is the severe cause of CVD or CLD if consumed frequently or at overdoses^16,18.

Drugs as Antihistamines:

Levocetirizine, Fexofenadine, Loratadine, Rupatadine, Cimetidine, Cetirizine are the most commonly used antihistamines. It is advised that antihistamines should be administered in an empty stomach for better bioavailability^19,20. All the anti-histaminic drugs are for allergic conditions. Only Cimetidine is recommended with any meal to maintain therapeutic blood concentration^21-22.

Anti-tubercular Drugs:

Isoniazid, Pyrazinamide, Rifampin, Ethambutol are the drugs of choice for tuberculosis. Isoniazid often linked with tyramine. This combination may be the fatal cause of histamine interactions with so many foods. The foods (e.g., chickpeas, soybeans, peanuts, some kinds of seafood) are very interactive with Isoniazid²³. Monoamine oxidases are a group of enzymes that take away dopamine, serotonin, norepinephrine (neurotransmitters), which prevent a person from depression. Histaminase is vital to control allergy by controlling histamine. Both the drugs, MAO inhibitor, and antihistaminic, can cause significant drug-food interactions while co-administered with Isoniazid. Some foods reduce Isoniazid's bioavailability²⁴. Triterpenoid, Oleanolic acid are present in olive oil, garlic as well as in some herbal products. They have antimycobacterial functions against the Mycobacterium tuberculosis (T.B bacteria). The point should be noted that Oleanolic acid, while combined with Isoniazid, can provide significant results in human health²⁵.

Antidiabetic medicines:

Sulphonylureas group of antidiabetic drugs are usually taken immediately after a meal (except Gliclazide). Gliclazide and Glipizide should be given 30 minutes before a meal. If extended-release tablets are available, then it can be taken with breakfast. Glimepiride (a sulfonylurea derivative) is another antidiabetic drug that should be recommended in the morning breakfast. It has very high bioavailability if not having any food or drug-drug interaction. Metformin (under Biguanides) should be taken with or after meals^26,27,58.

Antitumor Drugs:

Mercaptopurine is a purine analogue used in the types of leukaemia. Patients who consume this drug must avoid cow's or buffalo's milk. Cow's milk contains a high amount of xanthine oxidase (X.O.). That enzyme reduces or interferes with the process of bioavailability of mercaptopurine. It's always advisable not to drink bovine milk along with this medicine; instead, allow the drug to work correctly. A patient must plan a diet to have milk at a different time on that day to avoid food-drug interaction²⁸. Another useful antitumor agent is tamoxifen. The drug induces regression of MCF-7 tumour size if consumed with sesame seeds by the negative impact mechanism.

On the other hand, the seeds beneficially react with the drug on bone and cartilage in ovariectomized athymic mice ²⁹. Xue et al. suggest that n-3 fatty acids, in combination with glutamine (a vital amino acid) might be helpful in colorectal cancer while co-administered with CPT-11(irinotecan/a topoisomerase inhibitor) treatment. CPT11 may kill cancer cells by inhibiting some harmful enzymes and repair DNA^30,55.

Antihypertensive Drugs:

Apart from medicine, DASH (Dietary approach to stop hypertension), diet is vital to practice by the hypertensive patients. Therefore, patients are advised to follow a sodium-restricted diet in which table salt should be less than 5gm^31,50. A high protein diet can elevate the serum level of propranolol, the drug of choice for hypertension. As per literature reviews, low carbohydrate, low-fat, but high protein diet may help hypertension patients due to better oral clearance until the absorption of this drug. Smoking may affect the absorption of this drug and elevates B.P³². Beta-blocker celiprolol can be changed when it is co-administered with any citrus juice due to poor absorption in the gastrointestinal tract. Orange juice contains hesperidin, which interferes with the bioavailability of the drug. On the contrary, felodipine, the Ca2 channel blocker, shows better bioavailability while consumed with grapefruit juice^33,38.

Bronchodilators:

Bronchodilators are used to treat Asthma, COPD. There are three types of bronchodilators: beta-adrenergic, anticholinergic, and xanthine derivatives bronchodilator. The commonly used medicine theophylline under the group of xanthine derivatives is highly effective when given with high-fat diet. Low carbohydrate but high fat (unsaturated fatty acids abundant) diet through the daily meals undoubtedly helpful and increase the bioavailability of the drug. Patients who are taking theophylline should avoid alcohol, which can interact and may cause nausea, vomiting, headache, and irritability. Particular caffeine-rich foods like coca-cola, chocolate, tea, and coffee) should be stopped taking along with theophylline, which is a xanthine derivative ³⁴. In addition to these, grapefruit juice also not right to take with theophylline³³.

Thyroid medicine:

Levothyroxine is a popular drug and perhaps a long-term treatment for hypothyroidism. From the level of subclinical till severe level (Myxedema), this is the drug of choice, which is recommended to consume early in the morning at an empty stomach. Literature pointed out that helicobacter pylori infection and gastric atrophy may be developed due to insufficient secretion of gastric acid and, subsequently, intestinal enzymes. This is because of the poor absorption of LT4 drug in the G.I level 35. Grapefruit juice also a small effect on the bioavailability of levothyroxine (LT4)^33-36.

Warfarin:

Warfarin (Coumadin, Jantoven) is an anticoagulant drug usually prescribed to prevent blood clotting and migration³⁷. As per Mayo Clinic, more than 120 medicines and foods cum supplements can interact with warfarin as examples: grapefruits, cranberries or cranberry juice, garlic, Ginseng, Green tea, alcohol, and more. In the daily diet, unnecessary protein consumption can increase the risk of hyperalbuminemia and CYP3A4 enzyme activity. As per the current study, the international normalized ratio (INRs) of any patient may get influenced by this kind of diet. We can say that Warfarin metabolism mostly depends on cytochrome P450, an essential enzyme to balance cholesterol, prostacyclin, and thromboxane A_2,steroids etc_.^38,59

Vitamin K is very high in vegetables like broccoli, parsley, spinach brussels sprouts, kale, etc. Eating these vegetables may impact food-drug interaction and the unsatisfactory result of warfarin treatment³⁹. Eating charbroiled foods, soy products, raw onion can also influence the bioavailability of warfarin^33,40. Studies showed that some interactions with few vegetables resulting in thromboembolic complications^41,42,43,44.

Foods as Endocrine Disruptorsp:

There are findings that coffee interferes with T4 absorption at G.I level⁴⁵. As per studies, people all over the world regularly purchase and eat some common foods within their daily meals. Literature wise, these foods may interact or affect the bioavailability of levothyroxine tablets (LT4). TSH and T4 levels may get deviated due to some other hormonal or comorbidity issues in humans. Usually, in hypothyroidism, free TSH is elevated, but the average or subnormal level of free T4.

On the contrary, hyperthyroidism shows the opposite incident. In general, hypothyroid patients should not consume or should very less amount eating habits to the consumed foods, as discussed here. They usually love to eat these foods provided dietary guidance through a nutritionist who can help by adding necessary awareness. The required knowledge can be imparted through various technology virtually commonly used by all nowadays. Undoubtedly, social media is also the best way to educate patients suffering from lifestyle disorders like diabetes, hypothyroidism, and obesity^46,50,51. As per exhaustive reviews on all conventional dietary approaches in India, the vegan diet somehow better than other diet types. That is having a common trend mainly in some states of India (northern and western India) and among the old generation. The vegan diet is the only diet pattern among ISKON members all over the world. This is one of the reasons that some people from western countries have been accepting and practising same⁴⁷. However, the vegan diet is composed of cereals, vegetables, and fruits, which may be interactive. The gluten from wheat products and foods contain goitrogen, thiocyanates, and flavonoids. Cruciferous vegetables contain goitrogens and thiocyanates. As examples: cauliflower, broccoli, Brussel sprouts, sweet potatoes, cabbage, kale, mustard greens, rutabagas, spinach, turnips, rapeseed oil, soy-based foods. The severe goitrogenic effect may be seen through tofu, tempeh, soya milk. Thiocyanate effect due to starchy plants like cassava and others like corn, lima beans, linseed, millet. Some fruits may interfere with LT4, e.g., peaches, peanuts, pear, pine nuts, strawberries. Patients must be careful about flavonoids, which are also having a poor relationship with levothyroxine, e.g., all citrus fruits, tea, berries, apples, legumes etc.^48,49.

Table-1. Summary of common foods-drugs interactions (only a few included and considered good and bad both actions)

Name of Drugs	Interactive Foods
Alprazolam, Amiodarone, Carbamazepine, Loratadine, Fexofenadine, Erythromycin, Atorvastatin, Lovastatin,	Grapefruit juice ^7,9 Clarithromycin, ciprofloxacin
Fexofenadine, Aliskerin	Apple, orange juice⁹
Ciprofloxacin, Azithromycin, Tetracycline	Milk and milk products^{9, -13}
Ibuprofen, Naproxen, Ketoprofen,	Citrus fruits, apple (pectin)¹⁵, milk¹⁶, alcohol¹⁷acetaminophen.
Diclofenac potassium, Ibuprofen	Coca-cola, cola products¹⁸
Isoniazid	Chickpea, soybeans, peanuts, cheese²³
Monoamine oxidases Inhibitor	Salami, beef, chicken, sausages, red meat²⁴
Antihistaminic	Grapefruit ^7,9, coffee, alcohol,^23-24
Mercaptopurine	Bovine milk ²⁸
Tamoxifen.	Sesame seeds* (good effect) ²⁹
CPT-11 (irinotecan/a topoisomerase inhibitor)	Good interaction* glutamine+n3 fatty acid ³⁰
Propanolol	Low-fat, low carbohydrate diet, salt ^31,32
Celiprolol (beta-blocker)	Orange, orange juice ³⁸
Felodipine (Ca2 channel blocker)	Better bioavailability* if consumed with GFJ ³³
Theophylline	High-fat diet is effective* for bioavailbility³⁴
Xanthine derivatives (Theophylline)	Coffee, alcohol, chocolate, cola ³³ grapefruit ⁹
Levothyroxine	Grapefruit juice ^33-36, coffee, gluten from wheat products ⁴⁵, broccoli, Brussel sprouts, soy foods, cabbage, cauliflower, kale (presence of goitrogens& thiocyanate), mustard greens, rapeseed, rutabagas, spinach, turnips, sweet potatoes, rapeseed oil, are also interactive. citrus fruits, tea, berries, apples, legumes, coffee (presence of flavonoids) ^48,49
Warfarin	Grapefruits, cranberries or cranberry juice, garlic, ginseng, green tea, alcohol and more38.broccoli, soy and soy foods, parsley, spinach brussels sprouts, kale ^39,41,44. Good effect* by eating some charbroiled or cooked foods and raw onions, sweet corn, sweet potatoes, cucumber ³³.

The mark (*) mentioned-above means good effect or helpful interactions.

Essential awareness on nutrition to avoid the adverse effect of food-drug interaction:

People all over the world must be aware of essential food safety and health hazards knowledge to cope with their daily life. The ultimate objective is to maintain good health and staying as safe as possible. According to various health records, developed countries are implementing health policies by their health workers. Still, a country like India, Pakistan, Bangladesh, and other African countries are on the need to achieve mass awareness. Door to door campaigning, small diet and medical camps for ordinary people both in cities and rural areas should be mandatory. The audio or video training program on workload, stress, nutrition, and medical management should be there on lifestyle diseases, including liver disorders, diabetes, many ulcers, and cancers^50,51.

Nutritionists and doctors can take the best roles to educate ordinary people about the right foods and right nutraceuticals products for their diseases. The young generation who are also practising at the gym must get knowledge about safe supplements for building muscle mass. So the appropriate uses of neutraceuticals for various disorders should be brought under attention by the nutritionists at the community level through various NGOs. In developing countries, women and children from rural areas are more vulnerable due to low protein, low minerals, and low vitamin diet, and that is because of pre-existing economic challenges. However, children from the cities and the districts must be taken care of right foods, which should be rich in first-class protein, high dietary fibre, but low pure sugar foods-based diet^52,53.

Most importantly, junk food consumption should not be entertained to the school going children or any other students studying in the graduations or post-graduation level. Junk foods not only increase weight or different lifestyle diseases but also affect immunity. Generally, there is less chance of adverse interactions with any scheduled drug if we remove the so-called 'bad interactive foods' from our daily diet⁵²^-^54,57.

CONCLUSION:

Foods and drugs are both essential in our daily life because food is the source of energy, and the drug is the treatment recommended by the doctor. Both can be going on hand to hand provided some basic knowledge not only for doctors, nurses, and dietitians but even for ordinary people. Various researches show that more than 38% of people are suffering from lifestyle disorders all across the world. As a consequence, the purchase of multiple drugs (medicines) is also growing at a very high rate. The same people like to enjoy the foods also which give immense pleasure and self-satisfaction, but unknowingly there are so many interactions due to the simultaneous administration of drugs. This study not merely reviewed some significant food-drugs interaction but also presented and pointed out the need for necessary knowledge cum awareness of interactions and subsequent adverse.

CONFLICT OF INTEREST:

No conflict of interest.

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Received on 15.04.2020 Modified on 17.05.2020

Asian J. Pharm. Res. 2020; 10(3):188-194.

DOI: 10.5958/2231-5691.2020.00033.7