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Grapefruit Juice with Certain Medications Can Be
Deadly Mix
Jan. 18, 2005 - Grapefruit juice can be, and has
been, deadly for people on certain medications, nurse researchers remind
doctors, nurses, and everyone who takes medicine and enjoys grapefruit
juice, in a paper in the American Journal of Nursing, a journal of the
American Nurses Association. The authors also provide a list of drugs,
many frequently used by seniors, that interact with grapefruit juice.
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Amy Karch, R.N., M.S.,
of the School of Nursing at the University of Rochester Medical Center
reported on a man from a northern climate who moved to Florida for the
winter – one of tens of thousands of "snowbirds" who head south each
winter – and began drinking two to three glasses of grapefruit juice
each day. Two months later the man died, the victim of a deadly
interaction between grapefruit juice and his cholesterol-lowering
medication.
Karch's paper, "The
Grapefruit Challenge: The juice inhibits a crucial enzyme, with possibly
fatal consequences," appears in the December 2004 issue of the journal.
Interactions between
grapefruit juice and medications have long been recognized. Last year,
the Medical Letter on Drugs and Therapeutics devoted an entire issue to
grapefruit juice and the dangerous drug interactions that can result.
The U.S. Food & Drug Administration requires all prospective new drugs
to be tested for interactions with grapefruit juice. And a warning about
grapefruit juice is included in the "food-drug interactions" that come
with dozens of medications. Nevertheless, Karch says many health-care
professionals and patients don't know about the risk.
"The potential of drug
interactions with grapefruit juice has been out there a long time, but
most people just aren't aware of it," says Karch, a clinical associate
professor of nursing. "There is so much information bombarding people
all the time, that a lot of people may have heard this but forgotten it.
But the problems can be life-threatening."
The patient profiled in Karch's article had
high cholesterol and other risk factors for cardiac disease. The doctor
put the patient on atorvastatin (Lipitor), and the patient began dieting
and exercising. Two months after the patient went to Florida for the
winter, he suddenly had muscle pain, fatigue and fever, and went to the
emergency room. The patient ended up going into kidney failure and
ultimately died.
The only major change in
the person's lifestyle had been that, upon arriving in Florida, he began
picking grapefruit off a tree on the patio and drinking two or three
glasses of fresh grapefruit juice every day.
Karch, an expert on drug
interactions, explains that grapefruit juice is one of the foods most
likely to cause problems with drugs, because it is metabolized by the
same enzyme in the liver that breaks down many drugs. The cytochrome
P-450 3A4 enzyme breaks down grapefruit juice into useful components for
body, just like it breaks down dozens of medications. Karch says when
the system is overloaded, the grapefruit juice can "swamp" the system,
keeping the liver busy and blocking it from breaking down drugs and
other substances.
Drugs that use the same
pathway and interact with grapefruit juice target some of the most
common health problems doctors see today. The list consists of more than
50 medications, including some drugs used to treat high cholesterol,
depression, high blood pressure, cancer, depression, pain, impotence,
and allergies.
Karch notes that
interactions with grapefruit juice are well known and documented among
drug researchers, and that an appropriate warning label is included with
each prescription. Nevertheless, she says that many patients, nurses and
doctors aren't aware of the interactions or the potential serious
consequences, and that many people fail to read the warning labels about
drug-food interactions.
The consequences of an
interaction depend on the drug involved. A woman on birth-control pills
who drinks a lot of grapefruit juice might find herself pregnant because
the juice blocks the action of the medication. A person on an
anti-depressant might have too much or too little energy, depending on
the specific medication. Someone on antibiotics might end up with
diarrhea or could be ill longer than usual because the drug won't work
as well as it should. A heart patient might not get the lowered blood
pressure that a medication should deliver, or the heart's rhythms might
become irregular if an anti-arrhythmia drug can't do its job.
The most severe effects
are likely with some cholesterol-lowering medications, Karch says. While
the liver devotes its resources to grapefruit juice, the medication can
build up to dangerous levels, causing a breakdown of the body's muscles
and even kidney failure. This is what happened to the patient discussed
in the article.
To prevent such
problems, Karch repeats what doctors and nurses tell their patients
every day: Read a medication's warning label carefully. If an
interaction with grapefruit juice is possible, the patient should stop
drinking the juice until speaking with his or her doctor. In some cases
it might be possible to switch a patient to a different drug without the
risk; in other cases the patient might simply have to give up grapefruit
juice.
She says that more
people than usual are vulnerable at this time of year, because losing
weight is among the most popular New Year resolutions, and some diets
are built around drinking lots of grapefruit juice.
Karch's paper is the
latest in a column the journal devotes to "practice errors," where
nurses report unusual clinical problems and Karch looks into how
widespread the problem might be. Last year she also reported that nurses
had found that some types of skin patches could catch on fire when
patients receive magnetic resonance imaging (MRI) scans.
Drugs that
Interact with Grapefruit Juice:
(from the December 2004 issue of the American Journal of Nursing)
Antibiotics: clarithromycin, erythromycin,
troleandomycin
Anxiolytics: alprazolam, buspirone, midazolam, triazolam
Antiarrhythmics: amiodarone, quinidine
Anticoagulant: warfarin
Antiepileptic: carbamazepine
Antifungal: itraconazole
Anthelmintic: albendazole
Antihistamine: fexofenadine
Antineoplastics: cyclophosphamide, etoposide, ifosfamide, tamoxifen,
vinblastine, vincristine
Antitussive: dextromethorphan
Antivirals: amprenavir, indinavir, nelfinavir, ritonavir, saquinavir
Benign prostatic hyperplasia treatment: finasteride
â-blockers: carvedilol
Calcium channel blockers: diltiazem, felodipine, nicardipine, nifedipine,
nimodipine, nisoldipine, verapamil
Erectile dysfunction drugs: sildenafil, tadalafil
Hormone replacement: cortisol, estradiol, methylprednisolone,
progesterone, testosterone
Immunosuppressants: cyclosporine, sirolimus, tacrolimus
HMG-CoA reductase inhibitors: atorvastatin, fluvastatin, lovastatin,
simvastatin
Opioids: alfentanil, fentanyl, sufentanil
Selective serotonin reuptake inhibitors: fluvoxamine, sertraline
Xanthine: theophylline
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