Neurofeedback – How Attention Takes Flight Pierre Walther and Stephan Ellinger Goethe University Frankfurt, Julius-Maximillians-University Würzburg (GERMANY) Attention Deficit Disorder (ADD) alone or in combination with Hyperactivity (ADHD) is one of the most common disorders in childhood and adolescence and even persists into adulthood. Children with ADHD show a higher amount of slow brain waves and a decreased amount of faster brain waves compared to children without ADHD (Barry et al., 2003). The basic idea of neurofeedback is to transfer the unconscious process of brain wave function into a conscious process by reporting it to the patient. The Brainfeeders project aims to evaluate the possibilities for integrating neurofeedback in a school setting. The primary goal of the study is to replicate results found in clinical trials without any additional human resources. We would like to evaluate how well a training programme like this fits in school settings and if results are comparable to clinical studies. We are interested in forming a transnational working group, integrating researchers who are working on similar projects or who are interested in working on Brainfeeders in their countries.
Rd09-frx-forrd41Food Interactions with Prescription Drugs By Karen Lilyquist, RN, RD, PhD, LD Julie Stefanski, RDN, MEd, LDN, CDE Goal and Objectives The goal of this prescription drug-food interaction continuing education module is to inform dietitians, dietary managers, fitness professionals, health educators and occupational therapists regarding the adverse effects and effectiveness of prescription drugs caused by the intake of certain food, food substances and dietary supplements. After reading this module, the participant will be able to: • Identify at least five factors affecting the therapeutic outcome of drug therapy • Identify potential grapefruit-drug interactions and the potential effect on the body • Discuss dietary monitoring and modifications needed for medications discussed • Identify five common herbal preparations or supplements that interfere with the pharmacokinetics of certain drugs • Identify one drug classification that herbal preparations or supplements affect
See "How to Earn Continuing Education Credit" at the end of this course.
The number of Americans taking prescription drugs has been increasing each year. A record 4
billion drug prescriptions were written in the U.S. in 2011. The top medication classes of
prescribed medications include antidepressants, lipid regulators, narcotic analgesics, oral
hypoglycemics and angiotensin-converting enzyme (ACE) inhibitors.1 Polypharmacy, which can
contribute to adverse effects, is generally defined as the concurrent use of five or more
prescription medications. It is estimated that the average older adult living independently in the
U.S. uses six prescribed and OTC medications per day versus nine medications per
institutionalized older adult.2
Besides taking prescription drugs, many Americans use OTC medications, follow quirky diets
and ingest dietary supplements, including herbal preparations. Although drug-drug interactions
are often discussed by physicians and pharmacists, the possibility of negative adverse effects
caused by drugs interacting with food or supplements is often overlooked. Of the almost 900
drugs and fixed drug combinations used in the U.S:3
• More than 400 have the potential of interacting with food or food components • About 400 may deplete specific nutrients • More than 300 demonstrate interaction with dietary supplements A Drug's Effect A drug is prescribed to produce specific, desired effects; however, it can also produce undesired adverse effects, which range from being inconsequential (harmless), hazardous or even lethal. The goal of pharmacology is to maximize the benefits of a drug while minimizing its adverse effects. Food-drug interactions are related to the dose and form of the drug, the condition or disease for which the drug is prescribed, the client's characteristics and the diet prescribed for the client. While we may not be able to eliminate adverse effects, they can often be managed. Diet education is one method by which to reduce the risk of negative food-drug interactions. It is important to note that food is only one factor affecting the therapeutic outcome of drug therapy. Others include sex-related differences such as body composition (including fat-to-lean body mass ratios), hormonal differences, age and life cycle, genetics including metabolic rate, genetically determined enzymes, immune system, medical and nutritional status, placebo effect, generic vs. trade name drugs, and drug-drug interactions. Types of pharmacological interactions include (most interactions discussed here are pharmacokinetic):3 • Pharmacodynamic interaction: occurs when two substances have pharmacologic
actions that enhance or interfere with each other's actions (e.g., a drug's dose, action, onset, and duration, which ultimately produce the drug response) • Pharmacokinetic action: occurs when the absorption, distribution, metabolism and
excretion of one substance is altered by another. Specifically, pharmacokinetic mechanisms may include an alteration of GI or urinary pH, stimulation or inhibition of enzymes involved in metabolism or transport of drugs, displacement of a drug from the binding site to plasma proteins, and alteration of solubility. One common way that food affects drugs is by changing the way the drug is metabolized. Enzymes metabolize many drugs; certain foods make the enzymes work faster or slower, ultimately decreasing or increasing the time the drug spends in the body. The concentration of the drug in the plasma is altered accordingly. If a food increases the enzyme action, the drug will spend a shorter amount of time in the body than expected, have a lower concentration than expected and may be less effective. The opposite occurs if the food disrupts the enzyme that metabolizes the drug. That drug will spend a longer time in the body; it may have a high plasma concentration and may result in dangerous effects. A drug's absorption can also be affected by food. Like metabolism, food can increase or decrease the activity. For example, when vitamin C (citrus juice) is taken with iron supplements, iron absorption is increased; when milk is taken with tetracycline (Sumycin), the calcium in the milk binds to the tetracycline, forming an insoluble compound that the body cannot absorb. Food can interfere with the intended effects of the medication. For instance, vitamin K helps blood to clot. A change in vitamin K intake will alter the clot-preventing effect of warfarin (Coumadin). An increase in vitamin K intake reverses the effects of warfarin; a decrease in intake will potentiate bleeding. The opposite effect occurs with vitamin E and the "four Gs": garlic, ginseng, ginkgo biloba and ginger, as large amounts of these will increase the risk of bleeding. Food-Drug Interactions The interactions between food and drugs can be general or specific. When food interacts with drug absorption, it is generally a function of food binding to the drug. Food can either increase or decrease a drug's absorption throughout the GI tract. When food will delay and/or decrease the absorption of a drug, the drug should be taken on an empty stomach. Food-Drug Interactions With Food
• Ibuprofen (Advil, Motrin) • Fexofenadine (Allegra) • Indomethacin (Indocid) • Desloratadine (Clarinex) • Naproxen (Anaprox, Aleve) • Cetirizine (Zyrtec) • Enteric-coated aspirin • Acetaminophen (Tylenol) • Methylprednisolone (Medrol) • Prednisone (Orasone, Cortan, Deltasone) • Beclomethasone (Beconase, Vancenase, • Hydrocortisone *Aspirin can irritate the stomach lining and increases the risk for gastric bleeding; a buffered or enteric-coated aspirin is an option. The class of drugs known as corticosteroids can cause hyperglycemia, and includes drugs such as prednisone (Orasone, Cortan, Deltasone), prednisolone (Cortan, Deltasone), and cortisone (Cortone). Those with diabetes should check blood sugars frequently, as prescribed by a physician. Patients who take steroids must follow a certain meal plan, and medications used to lower blood sugar levels may need to be adjusted to compensate for hyperglycemia. Corticosteroids also affect calcium absorption from the intestines and increase loss of calcium in urine. Due to their impact on bone-calcium content, long-term use of corticosteroids may lead to osteoporosis. Grapefruit Grapefruit juice is one of the most extensively studied foods for its affect on medication. Still, because of its actions in reducing atherosclerotic plaque formation, inhibiting breast cancer cell proliferation, and certain antioxidant, antiseptic, cardiotonic, detoxicant, cholesterol lowering, and sedative qualities, many continue to drink it routinely. The substance in grapefruit that produces the interaction is found in both the fresh fruit and the juice. Citrus fruits such as grapefruits, tangelos, limes, Seville oranges (used in marmalade; also known as bitter orange), and pomelos contain active ingredients called furanocoumarins that irreversibly block the drug metabolizing enzyme cytochrome P-450 3A4. The liver cytochrome P-450 system is responsible for the first step in metabolism of many drugs. Inhibition of this enzyme alters the pharmacokinetics of a variety of medications, ultimately increasing their serum concentrations. In sum, the drugs metabolized by the associated enzymes are not dissolved as quickly as expected, which may cause more of the drug to be absorbed from the intestine. Grapefruit can increase oral drug bioavailability significantly, even to toxic levels.4 The severity of inhibition differs among clients, but can be quick and irreversible. It can reduce the levels of cellular cytochrome P-450 system enzymes as much as 47% within four hours of ingestion with the resultant increase in bioavailability of the drug for as long as 24 hours, when up to 30% of the drug's effect is still detectable.5 More than 85 prescription medications have demonstrated interactions with grapefruit. Of these, 43 can have serious adverse effects including sudden death, kidney failure, GI bleeding and rhabdomyolysis. Most notable are the effects on calcium-channel antagonists (drugs that have names that end in "pine," such as felodipine [Plendil], nifedipine [Procardia], and nisoldipine [Sular]), and the statin group of drugs (HMG-CoA reductase inhibitors).4 Drugs Affected by Grapefruit Certain benzodiazepines
• Midazolam (Versed) • Erythromycin (Erythrocin) Anticancer drugs
• Halofantrine (Halfan) • Maraviroc (Selzentry) • Carbamazepine (Carbatrol, Tegretol) • Atorvastatin (Lipitor) • Fexofenadine (Allegra) • Lovastatin (Mevacor) Antianxiety drugs
• Simvastatin (Zocor) • Diazepam (Valium) • Domperidone (Motilium) • Amiodarone (Cordarone) Hypnotics
• Dronedarone (Multaq) • Triazolam (Halcion) • Zaleplon (Sonata) • Buspirone (Buspar) • Sertraline (Zoloft) • Cyclosporine (Neoral, Sandimmune) • Ketamine (Ketalar) • Tacrolimus (Prograf) • Lurasidone (Latuda) • Sirolimus (Rapamune) Estrogen and oral contraceptives
Some erectile dysfunction drugs
* Note: for a complete list of drugs affected by grapefruit, see reference 4. Drugs within the classifications are affected differently by grapefruit juice. For example, some statins, such as simvastatin (Zocor), lovastatin (Mevacor) and atorvastatin (Lipitor), are affected; it does not appear that grapefruit components have an effect on pravastatin (Pravachol), fluvastatin (Lescol) and rosuvastatin (Crestor). Preliminary research indicates that cranberry and pomegranate items, olive oil, Seville oranges, grapes and black mulberries could have a similar, although less robust, effect on the pharmacokinetics of statins in the body. Pomegranate juice has become increasingly popular, but research is lacking regarding possible interactions. It is advisable to recommend avoidance of pomegranate juice for patients taking medication metabolized by cytochrome P-450 system enzymes.6 For maximum lipid-lowering effects, short-acting drugs (fluvastatin [Lescol], lovastatin [Mevacor], and simvastatin [Zocor]) should be taken in the evening. Evidence suggests that the liver synthesizes the majority of cholesterol in the early morning hours. Longer-acting statins (atorvastatin [Lipitor], pravastatin [Pravachol]) may be taken any time of the day, but should be taken at a consistent time each day. The list of drugs that are affected by grapefruit components can seem quite lengthy; however, only the medications metabolized by the cytochrome P-450 system enzymes will be affected by grapefruit juice. Many drugs treating the same conditions have been found to have a minimal/negligible interaction with grapefruit or no interaction at all. For example, ACE inhibitors (e.g., captopril [Capoten], enalapril [Vasotec], lisinopril [Prinivil, Zestril], ramipril [Altace]) have not shown any interaction with grapefruit, nor do the group of drugs known as antimicrobials (e.g., antivirals such as indinavir [Crixivan], a protease inhibitor that slows the spread of HIV infection in the body, and quinine [Qualaquin], an FDA-approved drug for the treatment of uncomplicated malaria). The antipsychotics clozapine (Clozaril) and haloperidol (Haldol) are not affected, nor are the anticonvulsant phenytoin (Dilantin). Other common drugs, such as cetirizine (Zyrtec) and loratadine (Claritin), are considered safe with grapefruit juice. As tangelos are a hybrid of grapefruit, advise clients to avoid them as well. Alcohol Medications may inhibit alcohol dehydrogenase, leading to a severe ethanol intoxication reaction. Alcohol interacts with most antidepressants, antibiotics, anticoagulants and other drugs used for neurological benefits. The concurrent use of alcohol and medications used to lower blood pressure may cause increased hypotensive effects. Adverse effects from combining alcohol with medications include flushing, syncope, nausea, vomiting, chest pain, headache and tachycardia. Clients should check with their pharmacist or physician as to whether alcohol is advisable. Caffeine Depending on the dose, caffeine has differing effects on the central nervous system, cardiovascular system and metabolism. An average intake of 85 mg to 250 mg (found in one to three cups of coffee) may result in a sense of alertness, decreased fatigue and clear thinking. Higher doses of 250 mg to 510 mg (three to six cups of coffee) can result in tremors, restlessness, nervousness and insomnia. In even higher doses, seizures and cardiovascular instability may occur. A lethal dose is 10 g (about 100 cups of coffee). Caffeine should be avoided when taking antimicrobials, such as ciprofloxacin (Cipro), levofloxacin (Levaquin), ofloxacin (Floxin) and trovafloxacin (Trovan). Taking these medications with caffeine-containing products can increase caffeine levels, leading to excitable symptoms. Caffeine should also be avoided with certain anti-anxiety drugs, specifically benzodiazepines (e.g. lorazepam (Ativan), diazepam (Valium), alprazolam (Xanax)). Caffeine will lessen the therapeutic effects of the drug and will increase excitability. Caffeine-containing products should be avoided when taking drugs used to control gastroesophageal reflux or heartburn, as caffeine may irritate the stomach lining and worsen the conditions the patient is trying to control. These drugs include ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid) and nizatidine (Axid). Patients taking beta-blockers must also avoid caffeine. These drugs include metoprolol (Lopressor; Toprol XL), atenolol (Tenormin) and labetalol (Normodyne, Trandate). In a similar fashion, theophylline is related closely to caffeine. Drugs classified as bronchodilators are used to treat bronchial disease and include theophylline, albuterol (Ventolin, Proventil, Proventil-HFA, AccuNeb, Vospire, ProAir) and epinephrine. High-fat and high-carbohydrate meals can interfere with theophylline depending on the form of the drug. For example, food has no effect on (regular release) Slo-bid or Theo-Dur; however, it interferes with the absorption of (extended-release) Theo-24 and Uniphyl, and the absorption of Theo-Dur Sprinkles in children. Both theophylline and caffeine are found in coffee and in tea. If clients take theophylline and consume coffee or tea, they are at risk for nausea, vomiting, insomnia, tremors, restlessness, uneven heartbeats and seizures (convulsions). Supplements containing bitter orange (Seville orange) contain the stimulant synephrine. Combining this substance with caffeine or medications that increase the QT interval of the heart rhythm, such as disopyramide (Norpace), amiodarone (Cordarone), ibutilide (Corvert), quinidine (Cardioquin), dofetilide (Tikosyn), procainamide (Pronestyl), thioridazine (Mellaril) and sotalol (Betapace), can lead to cardiac arrhythmias.7 Bitter orange also contains tyramine and should not be used with monoamine oxidase inhibitors (MAOIs).8 Potassium The amount of potassium needed in a client's diet depends on which medications he or she is taking. For example, most diuretics cause a loss of potassium; furosemide (Lasix) is an example of a potassium wasting drug. Hydrochlorothiazide/triamterene (Dyazide, Maxzide) causes potassium to be spared (retained) in the body. Potassium intake must be monitored, maintaining consistent intake similar to the amount at the time the therapeutic dose was established. Potassium is an electrolyte with a narrow margin for error. If a client has too little potassium, he or she may experience weakness accompanied by abnormal heart rhythms, a breakdown of muscle fibers, fatigue, muscle weakness and even paralysis. If a client has too much potassium, nausea, irregular heart beat and possibly a slow, weak or absent pulse may occur. Examples of high-potassium foods include papaya, prune juice, melon, bananas, raisins, mango, kiwi, oranges, tomatoes, potatoes, avocados, asparagus and Brussels sprouts. ACE inhibitors, which are used to treat high blood pressure and heart failure, respond to potassium. Benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), lisinopril (Zestril), moexipril (Univasc) and ramipril (Altace) can increase the potassium levels in the body, thus one must limit or not exceed one's norm of potassium. Some herbal remedies can alter potassium levels. Chronic use of Senna, used to treat constipation, can lead to potassium loss that may increase the potential for digoxin toxicity. Licorice root, which contains glycyrrhizic acid, can also deplete potassium in the body, leading to abnormal heart rhythms if consumed in large quantities. It may also interfere with the effects of some diuretics and drugs commonly prescribed for high blood pressure. Vitamin K Vitamin K, which is produced in the gut by certain bacteria, plays a role in the body's normal production of some clotting factors. When these intestinal bacteria are destroyed by prolonged use of antibiotics and malnourishment, bleeding patterns can be altered. Any change in vitamin K level can interfere with blood clotting. Anticoagulants prevent blood clot formation that can cause a heart attack or stroke. One example is warfarin (Coumadin), a blood thinner. Vitamin K is an antagonist — it makes the blood clot— and it inhibits the action of warfarin, which is highly sensitive to interactions and changes in the diet. Those taking warfarin or other blood thinners do not need to avoid high vitamin K foods such as spinach, kale, turnip greens, cauliflower, broccoli, Brussels sprouts, leafy greens and some vegetable oils and nuts, but they need to avoid large amounts of these foods and keep intake consistent to find the proper dose of the drug. Vitamin K has the same effect on other blood-thinning medications, such as aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Cephalosporins can alter the absorption of vitamin K; other drugs, such as phenytoin (Dilantin), can interfere with the body's ability to use vitamin K. In addition, long-term use of antibiotics can result in vitamin K deficiency, as these drugs kill bacteria, both harmful and beneficial bacteria that activate vitamin K. Orlistat (Xenical, Alli), a weight-loss drug, and olestra (Olean), a substance added to foods to prevent the absorption of fat, can reduce the body's ability to absorb fat-soluble vitamins, including vitamin K. The FDA has mandated that vitamin K be added to food items containing olestra. Large amounts of vitamins A and E have been found to antagonize vitamin K; in essence, to potentiate the effects of anticoagulants and platelet inhibitors. Excess vitamin A appears to interfere with vitamin K absorption, whereas vitamin E may interfere with the functions of vitamin K–dependent clotting factors. Tyramine MAOIs (Nardil, Parnate), are a group of drugs used to treat depression. Many dietary restrictions exist for those taking this classification of medication. Linezolid (Zyvox), a synthetic antibiotic and member of the oxazolidinone class of drugs, is used for the treatment of vancomycin-resistant infections and pneumonia. Linezolid is a weak MAOI, and should not be used in conjunction with other MAOIs or foods containing high amounts of tyramine. GI monoamine oxidase is required for adequate breakdown of tyramine, an essential amino acid. Absorption of incompletely broken-down tyramine can result in toxic elevation of catecholamine levels, leading to headaches, nausea and hypertension. For example, one must limit the amount of tyramine to prevent a possible fatal raise in blood pressure or stroke. If MAOIs are taken with foods high in tyramine, a rapid, fatal increase in blood pressure may occur. Foods High in Tyramine • Processed cheese (American, cheddar, blue, • Yeast extracts brie, mozzarella, parmesan) • Beef or chicken liver • Cured meats (sausage/salami) • Caffeine drinks (coffee, tea, • Beer and red wine chocolate, cola) Parkinson's disease may also be treated with MAOIs such as rasagiline (Azilect) or other medications such as carbidopa-levodopa (Sinemet), which increase availability of levodopa to the brain. The prescribing neurologist may advise patients to consume the medication without food to increase absorption; to avoid fava beans, which contain levodopa; or to monitor excessive intake of protein as aromatic amino acids contained in protein-rich foods may compete with medications for intestinal absorption and eventual transport across the blood-brain barrier, lessening the effectiveness of the medication.9,10 Vitamin E Vitamin E, which is an antioxidant, is used by some to lower the risk of heart disease and stroke as it may help to prevent the oxidation of LDL cholesterol. While deficiencies are rare, too much can inhibit the action of vitamin K and increase the effect of anticoagulant medication. Vitamin E may also interfere with the body's ability to absorb the antidepressant desipramine (Norpramin), the antipsychotic chlorpromazine (Thorazine), and the beta-blocker propranolol (Inderal).
Bile acid–binding resins (cholestyramine [Questran], colestipol [Colestid]), isoniazid (Tubizid),
mineral oil, orlistat and olestra may decrease the absorption of vitamin E. Anticonvulsant drugs,
such as phenobarbital, phenytoin (Dilantin) or carbamazepine (Tegretol), may decrease plasma
levels of vitamin E.
Calcium supplementation may decrease the absorption of beta-blockers propranolol (Inderal) and
atenolol (Tenormin). Calcium supplementation may decrease the effect of calcium-channel
blockers (nifedipine [Procardia], verapamil [Isoptin], and diltiazem [Cardizem]). Those taking
calcium-channel blockers need to avoid licorice and grapefruit. Those taking
hydrochlorothiazide and calcium supplementation are at risk for hypercalcemia. When taking
digoxin (Lanoxin), one should also use caution with calcium or vitamin D supplementation as
either may increase the drug's effect and risk of toxicity. High-bran and high-pectin foods can
decrease absorption of digoxin, and should be avoided. Calcium can also bind and reduce
absorption of levothyroxine. Calcium supplements should be taken at least four hours apart from
The Four Gs
Garlic is used as an antimicrobial, and to lower cholesterol and blood pressure. It is generally
considered safe, but adverse effects can include fatigue, headaches and upset stomach. Garlic and
other herbal supplements have not been evaluated by the FDA for safety, purity and
effectiveness. Herbal preparations, although natural, may not necessarily be safe with standard
Ginger is used most often for its anti-nausea and anti-inflammatory properties.
Ginkgo biloba has been used traditionally to improve mental and cognitive function, to slow
macular degeneration, and to improve blood circulation. It is also used for its antioxidant actions.
Ginseng is used to reduce stress and fatigue and to improve stamina, healing and well-being.
While these benefits encourage the use of garlic, ginger, ginkgo biloba, and Asian ginseng, all
potentiate bleeding by inhibiting blood coagulation and echoing the action of aspirin, anti-
coagulants (warfarin, heparin) and antiplatelet drugs such as clopidogrel (Plavix). All are
contraindicated in clients with bleeding disorders. Glucosamine and parsley also have antiplatelet
Garlic, ginkgo biloba and ginseng may lower blood sugar. None should be taken if a patient is already taking insulin or oral hypoglycemic drugs. In addition, garlic can interfere with the absorption of isoniazid (INH). It may increase the body's breakdown rate of the protease inhibitor saquinavir (Invirase) and of non-nucleoside reverse transcriptase inhibitors (NNRTIs), medications used for HIV, decreasing the effectiveness of the medications. High doses of ginkgo biloba can decrease the effectiveness of anticonvulsant medications such as carbamazepine (Tegretol) or valproic acid (Depakote). Taking ginkgo in conjunction with selective serotonin-reuptake inhibitors (SSRIs), including escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft), may cause serotonin syndrome. Symptoms include tachycardia, hyperthermia, restlessness and sweating. Ginkgo can lower blood pressure; therefore, antihypertensive medications, specifically nifedipine (Procardia), should be used cautiously with this drug classification. Be aware that cellasene, which is promoted to eliminate cellulite, increases the risk of bleeding as it contains ginkgo, fish oil, sweet clover, bladderwrack, grape seed extract, borage seed oil and lecithin. Asian ginseng may alter the effects of calcium-channel blockers, block the analgesic effects of morphine, raise concentrations of certain medications, and potentiate the effects of anti-psychotic medications. Ginseng can also increase the effect of caffeine and other drugs that stimulate the central nervous system, resulting in nervousness, sweating, insomnia and irregular heart rate. Ginseng, in addition to guarana (used to treat drowsiness), licorice root (used to treat peptic ulcers) and yohimbe (used to treat impotence), can increase blood pressure. Each could negate the effects of antihypertensive medication. St. John's Wort St. John's wort, used as an antidepressant, can increase or decrease the effect of a number of prescription drugs including digoxin (lowering its concentration), blood thinners, antidepressants, the antiviral drug invirase, the anti-rejection drug cyclosporine, oral contraceptives and some cancer medications. St. John's wort stimulates cells to increase hepatic expression of CYP3A4 and acts to reduce the potency of medications broken down by this enzyme. Clopidogrel (Plavix) is an exception to this action. Due to the fact that it needs to be metabolized by this enzyme to become active, St. John's wort will increase the activity of clopidogrel.12 Fatty Acids Research suggests that taking the recommended amount of omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), in the form of fish oil supplementation may provide cardiovascular protective benefits through lowering blood pressure and triglycerides, and reducing inflammation in the body. Fish oils have the same interfering action with platelet aggregation as noted above and can interfere with aspirin, anticoagulants, antiplatelet drugs and NSAIDs. In addition, fish oils can lead to a potential vitamin E deficiency when taken for longer periods due to the role of vitamin E in the oxidation of the fish oil supplements. These supplements can also increase the action of anti-hypertensive medications, lowering the blood pressure too much. Taking orlistat (Xenical, Alli) in combination with fish oils can decrease absorption. Other Interactions Hawthorn leaf, which is used to lower blood pressure, reduce the frequency of chest pain, treat irregular heart rhythms and limit atherosclerosis, should not be used with digoxin. The herb may lower the heart rate too much, possibly causing heart failure. In addition, it should not be taken with antihypertensive medication as it will augment the work of the drugs. The following herbs should be not be mixed with blood thinners: • Angelica: used to treat gynecologic disorders • Chamomile: used to treat stomach disorders • Coenzyme Q-10: used to treat cardiomyopathy and as an immune system enhancer • Feverfew: used to control migraine headaches and reduce inflammation • Green tea: used to prevent high cholesterol • Guarana: used to treat drowsiness • St. John's wort: used as an antidepressant Antibiotics (e.g., cephalosporins, macrolides, penicillins, quinolones sulfonamides and tetracylines) can contribute to stomach upset, but they can also be affected significantly by nutrient interactions. One must be cautious when consuming calcium-containing foods, minerals (e.g., iron) and antacids while taking quinolones (ciprofloxacin [Cipro]) and tetracylines (doxycycline [Vibramycin], minocycline [Minocin]), as they decrease the drug concentration. Calcium, iron or zinc supplements; antacids; multivitamin supplements and dairy products should be taken two hours before or two hours after taking these medications. Tetracycline and several antifungal agents (fluconazole [Diflucan], griseofulvin [Grifulvin], ketoconazole [Nizoral]) do not work as expected when consumed with dairy products. Dairy products inhibit absorption. Iron supplements can also cause tetracycline not to work well. Bisphosphonates such as alendronate (Fosamax), ibandronate (Boniva), and risedronate (Actonel) must be taken with plain water at least 30 minutes before taking any other food or beverage as they will markedly reduce the absorption and effectiveness of these drugs. Ibandronate must have a one-hour window between its ingestion and ingestion of other items. Conclusion In sum, interactions between food and drugs can have a significant influence on the success of drug treatment. Interactions are not always considered negative, as some interactions may increase effectiveness of the drug or decrease the potential adverse effects, yet it is generally the detrimental outcomes that are not anticipated. Herbal preparations add to the concerns as these products are not highly regulated or monitored, may contain little of the advertised substance if any, and may contain substances not anticipated. Some herbal preparations, like certain foods, can interact adversely with specific medications. Gannett Education guarantees that this educational activity is free from bias. Karen Lilyquist, RN, RD, PhD, LD, has taught nutrition classes for the University of Phoenix and moderated teleconferences for the National Institute for Health Education and Training. She has counselled clients about weight control and food-related issues and has developed and coordinated diet therapy and nutritional education programs. Julie Stefanski, RD, MEd, LDN, CDE, is an outpatient dietitian at York Hospital, York, Pa., and adjunct professor in the department of nursing at York College of Pennsylvania. The authors have declared no real or perceived conflicts of interest that relate to this educational activity. References 1. IMS Institute for Healthcare Informatics. The Use of Medicines in the United States: Review of 2011. Parsippany, NJ: IMS Health Incorporated; 2012. 2. Heuberger R. Polypharmacy and food-drug interactions among older persons: a review. J Nutr Gerontol Geriatr. 2012;31(4):325-403. 3. Galland L. Interactions in clinical practice: drug-supplement, drug-nutrient. http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCoQFjAA&url=http%3A%2F%2Fmdheal.org%2Fhealthprofessionals%2Fppt%2Fdrugsupplementinteractions.
ppt&ei=pfL7UaaQE9Sr4APU0IG4Aw&usg=AFQjCNFCOejOQa6z_cYh9BL1mQVzrHDehQ&bvm=bv.50165853,d.dmg. 2010. Applied Nutrition, Inc. Accessed September 25, 2013. 4. Bailey DG, Dresser G, Arnold JM. Grapefruit-medication interactions: forbidden fruit or avoidable consequences? CMAJ. 2013;185(4):309-316. 5. Kiani J, Imam SZ. Medicinal importance of grapefruit juice and its interaction with various drugs. Nutr J. 2007;6:33. 6. Hidaka M, Okumura M, Fujita K, et al. Effects of pomegranate juice on human cytochrome p450 3A (CYP3A) and carbamazepine pharmacokinetics in rats. Drug Metab Dispos. 2005;33(5):644-648. 7. Nasir JM, Durning SJ, Ferguson M, Barold HS, Haigney MC. Exercise-induced syncope associated with QT prolongation and ephedra-free Xenadrine. Mayo Clin Proc. 2004;79(8):1059-1062. 8. Penzak SR, Jann MW, Cold JA, et al. Seville (sour) orange juice: synephrine content and cardiovascular effects in normotensive adults. J Clin Pharmacol. 2001;41(10):1059-1063. 9. Cereda E, Barichella M, Pezzoli G. Controlled-protein dietary regimens for Parkinson's disease. Nutr Neurosci. 2010:13(1):29-32. 10. Varanese S, Birnbaum Z, Rossi R, Di Rocco A. Treatment of advanced Parkinson's disease. Parkinsons Dis. 2011;2010:480260. 11. Butner LE, Fulco PP, Feldman G, et al. Calcium carbonate-induced hypothyroidism. Ann Intern Med. 2000;132(7):595. 12. Lau WC, Carville DGM, Guyer KE, et al. [Presentation]. St. John's wort enhances the platelet inhibitory effect of clopidogrel in clopidogrel "resistant" healthy volunteers. Presented at American College of Cardiology Annual Meeting, March 6-9, 2005. Orlando, FL; 2005:1043-129. Clinical Vignette Ted, 68, lives with his wife and adult daughter. He is a nonsmoker who has been diagnosed with diabetes, Parkinson's disease, hypertension and hyperlipidemia. He is 5 ft. 9 in. and weighs 164 lb. He occasionally drinks a glass of wine, and his daughter and wife cook his meals. He reports losing 10 lb over the past three months. Ted's prescribed medications include: • Simvastatin (Zocor) 40 mg • Metformin HCL (Glucophage) 500 mg • Tamsulosin HCL (Flomax) 50 mcg • Lisinopril (Zestril) 10 mg • Rasagiline (Azilect)1 mg • Carbidopa-levodopa (Sinemet) 100 mg TID
Ted is also taking cod liver oil, 1 tablespoon per day.
1. How many of Ted's medications have possible significant food-drug interactions?
2. Ted's neurologist has advised him to take carbidopa-levodopa (Sinemet) on an empty
stomach. What is the benefit of taking certain medications on an empty stomach?
a. It can decrease hydrochloric acid production.
b. It can decrease absorption of the medication.
c. It can increase absorption of the medication.
d. It can decrease GI distress.
3. Ted has not been feeling well and has developed progressively worsening headaches. He
has not made any changes to his intake of foods. Which medication and food substance
could be causing Ted's headaches?
a. Metformin and fatty acids
b. Rasagiline and tyramine
c. Lisinopril and vitamin C
d. Tamsulosin and sodium
4. Ted complains of occasional difficulty swallowing chunks of meat and is having
increased problems with constipation. He has tried increasing water and fiber. He has
occasional nausea without vomiting, and has a normal sense of smell and taste. He says his
appetite is good, and conveys the following dietary recall:
Breakfast: 2 packets of oatmeal with ½ cup 2% milk; ½ cup orange, apple or grapefruit juice
Snack: 1 tangerine and 2 oz Muenster cheese
Lunch: ½ ham sandwich, ½ cup potato salad, ½ cup chocolate milk
Supper: Linguini with clam sauce; or salmon cake, salad and applesauce
Snack: 3 olives or 1 apple
When asked how often he chooses grapefruit juice at breakfast, Ted states "once in a while."
Should Ted consume grapefruit juice with his current medications?
1. How many prescribed and OTC medications is it estimated that the average community-
dwelling older adult in the U.S. uses?
2. Prescription drugs can interact with:
b. OTC drugs
c. Herbal preparations
d. Dietary supplements
e. All of the above
3. When certain foods make enzymes work faster, the drug will spend a longer amount of
time in the body than expected, resulting in a higher plasma drug concentration.
4. Which of the following medications should be taken with food?
a. Fexofenadine (Allegra)
b. Ibuprofen (Advil, Motrin)
c. Acetaminophen (Tylenol)
d. Desloratadine (Claritin)
5. Clients should NOT consume grapefruit (fruit or juice) if they are taking:
a. Haloperidol (Haldol)
b. Carbamazepine (Tegretol)
c. Phenytoin (Dilantin)
d. Pravastatin (Pravachol)
6. Caffeine must be limited or avoided if your client is taking:
d. Oral diabetic agents
7. Those taking potassium-wasting diuretics such as furosemide (Lasix) must monitor
potassium intake. Which is an appropriate action?
a. Increase daily intake of canned soups.
b. Eliminate banana and oranges from the diet.
c. Monitor intake of potassium, maintaining consistent intake, similar to the amount taken when
the therapeutic dose was established. d. Add licorice root to the daily diet.
8. Vitamin K levels in the body are affected by:
a. Dietary intake of green leafy vegetables
b. Long-term use of antibiotics
c. Vitamin A supplements
d. Vitamin E supplements
e. All of the above
9. High-bran and high-pectin foods will decrease the absorption of:
b. Digoxin (Lanoxin)
d. Vitamin K
e. Vitamin C
10. What do garlic, ginger, ginkgo biloba and Asian ginseng have in common?
a. All potentiate bleeding.
b. All lower blood sugar.
c. All decrease the effectiveness of anticonvulsant medications.
d. All interfere with the absorption of INH.
11. While beneficial, omega-3 fatty acids can:
a. Cause vitamin A deficiency
b. Cause vitamin E toxicity
c. Inhibit platelet aggregation similar to the effects of aspirin, anticoagulants, antiplatelet drugs
d. Potentiate the effects of anti-psychotic drugs
12. When prescribed a new medication, a client should:
a. Stop taking all similar drugs
b. Add herbal preparations to offset the action of the new drug
c. Discuss all medication with pharmacist, physician and dietitian to identify any potential food-
drug interactions d. Do nothing different; just add the new drug to daily regimen How to Earn Continuing Education Credit
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