Nd2002: Drug food/nutrient interactions and polypharmacy- Nutraceuticals and herbal remedies, gut microbiome and probiotics.

What is the main consequence of polypharmacy in patients?

Increased likelihood of drug–nutrient interactions

Multimorbidity primarily leads to:

Complexity of therapeutic management for both health professionals and patients.

According to the National Service Framework for Older People (2001), older individuals should not:

should not suffer unnecessarily from illness caused by excessive, inappropriate, or inadequate consumption of medicines.

Which of the following drugs should be taken on an empty stomach due to reduced absorption with food? 1 hour before or 2 hours after meals, because food reduces its absorption.

Flucloxacillin

Which of the drug can be taken on an a full stomach? 1 hour before or 2 hours after meals, because food reduces its absorption.

Digoxin

Advise to leave a 2-hour gap between drug and dairy consumption typically when taking.

Antibiotics, Thyroid Medication, Osteoporosis Medication (Bisphosphonates).

What is the recommended advice for drugs affected by food in the stomach?

1 hour before food 

Which type of foods reduce the absorption of ciprofloxacin?

Dairy products

What is the recommended time gap between dairy intake and certain antibiotics (e.g. tetracyclines)?

2 hours

Absorption affected by enteral feeds 

Ciprofloxacin, Digoxin, Phenytoin, Rifampicin, Tetracycline, Theophylline.

Drugs affected by a high-carbohydrate or high-protein diet.

Theophylline, propranolol, antipyrine, and levodopa.

Metabolism affected by grapefruit/grapefruit juice 

Pravastatin (Pravachol), Haloperidol (Haldol), Diltiazem (Cardizem).

Enteral feeding has what effect on certain drugs like phenytoin?

Reduces absorption

What is the recommended strategy when administering drugs with enteral feeds?

Leave a time gap between feed and medication

Large intake of green vegetables can affect warfarin by:

reduce the effectiveness of warfarin (a blood thinner) because they are rich in Vitamin K

Vitamin __ - anticoagulant effect of warfarin increased 

Vitamin E

Drugs Metabolism affected by vitamin B6 (pyridoxine) What is false

Vitamin B6 can be stored in the muscles. Taking high doses—even as low as 50 mg daily over a long period—can lead to peripheral neuropathy, causing tingling or permanent nerve damage.

Excretion is affected by increased and decreased __ intake. 

Advise to keep __ intake constant once stabilised on lithium. 

Excretion is affected by increased and decreased salt intake. 

Advise to keep sodium intake constant once stabilised on lithium. 

Polypharmacy is not linked with:

Optimisation of medications where usage agrees with the some evidence.

What defines alternative therapies?

Used instead of conventional treatment. Complementary therapies. Used together with conventional treatment (e.g. acupuncture + analgesics to treat pain). 

Forms of alternative/complementary therapy do not include:

Treatments regulated and standardly prescribed by the NHS.

Reasons for people using alternative/complementary therapies not

Told by doctor who is qualified with NHS.

Nutraceuticals, Characterised as_

specially designed preparations (formulations) 

Cardiovascular Diseases 

Omega-3 Fatty acids, Garlic.

Skin Diseases 

Bioactive, Botanical Extract, Bioactive Peptide, Carotenoid Supplementation. Bioactive Polysaccharides.

Cancer (Chemo & Radio Therapy) 

Genistein, Curcumin, Ginger, Silibinin, Soy Isoflavones.

Common drug-herb interactions - St John’s Wort 

Antidepressants, Antiretrovirals (HIV PIs, NNRTIs-HIV protease enzyme), Anticonvulsants (epilepsy and seizures), Digoxin (heart failure and atrial fibrillation), Theophylline (asthma and COPD), Warfarin (blood thinner) and SSRIs (Selective Serotonin Reuptake Inhibitors-antidepressants). 

Common drug-herb interactions - Ginkgo biloba

Warfarin (anticoagulant), Aspirin (antiplatelet). Results in increased bleeding risk. 

Common drug-herb interactions - Echinacea

immunosuppressants

What herbal remedies interact with Warfarin (blood thinner).

St John’s Wort, Ginkgo biloba, Ginseng, Dong qual, Saw palmetto.

Used for- St John’s Wort 

treat depression. 

Used for- Ginkgo biloba

improving memory, anxiety and stress. 

Used for- Ginseng

improve well-being, energy and stress reduction.

Used for- Dong qual (female ginseng)

 treat reproductive problems in women, painful menstruation, improve blood flow 

Used for- Echinacea

Improve immune function, reduce inflammation, pain relief. 

Used for- Saw palmetto

Treatment of enlarged prostate in men. 

Used for- Turmeric

Relieving pain. Improving physical symptoms of osteoarthritis.

Used for- Curcumin

anti-inflammatory activity.

Used for- Manuka honey

Antibacterial, Antioxidant, Anti-inflammatory, Prebiotic.

Ginseng in cancer treatment. Patients treated with fluoropyrimidine-based chemotherapy plus Ginseng-containing traditional medicine preparations compared with FBC alone.  

Higher proportions of CD3+ T cells, CD4+ T cells, and natural killer cells, CD4+/CD8+ T-cell ratio. 

Possible adverse effects of vitamin and mineral supplements- Beta-carotene

May increase risk of lung cancer. Should not be taken by people who smoke.

Possible adverse effects of vitamin and mineral supplements- Vitamin A

Excessive doses- teratogenic, irreversible bone and liver damage. Avoid supplements in pregnancy, older adults at risk of osteoporosis, high intakes of liver. 

Possible adverse effects of vitamin and mineral supplements- Nicotinic acid (vitamin B3)

“Niacin flush” and gastrointestinal disturbances (reversible). Prolonged high dose intakes -> liver dysfunction.

Possible adverse effects of vitamin and mineral supplements- Vitamin C

Abdominal pain and diarrhoea at >1000 mg/day

Possible adverse effects of vitamin and mineral supplements- Vitamin B6

May cause irreversible neurological damage >200 mg/day

Possible adverse effects of vitamin and mineral supplements- Calcium

1,500 mg/day – abdominal pain and diarrhoea

Possible adverse effects of vitamin and mineral supplements- Iron

17 mg/day – constipation, nausea, abdominal pain 

Possible adverse effects of vitamin and mineral supplements- Magnesium

400 mg/day – osmotic diarrhoea

Professional values and ethics

First, do no harm. Autonomy. Respect for dignity.

Risks of taking a supplement with Effervescent (fizzy) vitamin supplements

contain approximately a gram of salt per tablet. 

What should you consider changing with Effervescent (fizzy) vitamin supplements?

Consider changing to a non-effervescent alternative -especially if advised to limit salt intake 

The safety of a supplement depends on a number of factors not

How it looks in size

Grapefruit Juice- Which of the following best describes the effect of grapefruit juice on Blood pressure medications?

Increases drug concentration

Grapefruit Juice- Which of the following best describes the effect of grapefruit juice on Statins medications (lower low-density lipoprotein (LDL) "bad" cholesterol)?

Increases statin levels

Grapefruit Juice- Which of the following best describes the effect of grapefruit juice on Psychiatric medications?

Increases drug levels

Grapefruit Juice- Does not reduce effectiveness; it increases _______ levels → Leading to a _______ risk.

Grapefruit Juice- Does not reduce effectiveness; it increases drug levels → Leading to a Toxicity risk.

Dairy products do not reduce absorption of which of the following?

Antihistamines- 1st Gen antihistamines (e.g. Hydroxyzine, Doxylamine).

What is false about the Vitamin K & Drug Interaction with Warfarin?

Role of Vitamin K and Warfarin together- Competes with drugs using amino acid transport systems.

Advice to be given to patients when taking Warfarin: Maintain _______ vitamin K intake to prevent _______ in the International Normalised Ratio (INR).

When taking Warfarin, maintain a consistent vitamin K intake to prevent fluctuations in International Normalised Ratio (INR).

Grapefruit Juice & Drug Interaction. Increases drug levels → Toxicity risk in what medications?

Blood pressure medications- Calcium channel blockers: Nifedipine, Felodipine, Amlodipine. And, Mineralocorticoid receptor antagonist: Eplerenone. Statin- Simvastatin, Lovastatin, Atorvastatin. Psychiatric medications- Diazepam, Buspirone, Sertraline.