Is the clinical relevance of drug-food and drug-herb interactions limited to grapefruit juice and Saint-John's Wort?

Enriching the FIDEO ontology with food-drug interactions from online knowledge sources

The increasing number of articles on adverse interactions that may occur when specific foods are consumed with certain drugs makes it difficult to keep up with the latest findings. Conflicting information is available in the scientific literature and specialized knowledge bases because interactions are described in an unstructured or semi-structured format. The FIDEO ontology aims to integrate and represent information about food-drug interactions in a structured way. This article reports on the new version of this ontology in which more than 1700 interactions are integrated from two online resources: DrugBank and Hedrine. These food-drug interactions have been represented in FIDEO in the form of precompiled concepts, each of which specifies both the food and the drug involved. Additionally, competency questions that can be answered are reviewed, and avenues for further enrichment are discussed.

Drug-Drug Interactions Involving Dexamethasone in Clinical Practice: Myth or Reality?

Concomitant administration of multiple drugs frequently causes severe pharmacokinetic or pharmacodynamic drug-drug interactions (DDIs) resulting in the possibility of enhanced toxicity and/or treatment failure. The activity of cytochrome P450 (CYP) 3A4 and P-glycoprotein (P-gp), a drug efflux pump sharing localization and substrate affinities with CYP3A4, is a critical determinant of drug clearance, interindividual variability in drug disposition and clinical efficacy, and appears to be involved in the mechanism of numerous clinically relevant DDIs, including those involving dexamethasone. The recent increase in the use of high doses of dexamethasone during the COVID-19 pandemic have emphasized the need for better knowledge of the clinical significance of drug-drug interactions involving dexamethasone in the clinical setting. We therefore aimed to review the already published evidence for various DDIs involving dexamethasone in vitro in cell culture systems and in vivo in animal models and humans.

Pharmacokinetic and pharmacodynamic drug-drug interaction of Nomilin with atorvastatin in hyperlipidemic mice

Atorvastatin (Atv) is widely used to lower cholesterol levels and treat hyperlipidemia in clinical application. Nomilin (Nom) is a kind of limonoids, which is found and isolated from the citrus herbs of Rutaceae family, which are widely used as patent medicines, functional foods, and nutritional supplements in many countries. In previous studies, Nom has the effect of anti-obesity and curing other metabolic diseases. Nevertheless, in recent years, the drug-drug interaction (DDI) caused by the administration of drugs with synergistic effects have raised worldwide concerns. To investigate the DDI of Nom and Atv in vivo, the pharmacokinetic studies were performed with using C57BL/6 mice. The plasma concentrations of Nom and Atv were measured after oral administration of different drug combinations by a simple and sensitive UHPLC-MS/MS method. The experimental mice were randomly divided into five groups, including control group, model group, administered Nom individually group, administered Atv individually group and co-administered of Nom and Atv group. The lipid levels including total cholesterol (TC), triglycerides (TG), high density lipoproteins-cholesterol (HDL-C), low density lipoproteins-cholesterol (LDL-C) were measured for pharmacodynamic study. The hepatic microsomal Cytochrome P450 (CYP1A2, CYP2E1 and CYP3A11) activities were probed using cocktail assay. The gene and protein expressions of CYP3A11 were detected via qPCR and Western blot method. The results shown that the area under the plasma concentration-time curve (AUC) of Atv in administered Atv individually group was 69.30 ± 15.45 ng/mL × h, while that of combined Nom with Atv group was 42.37 ± 10.15 ng/mL × h (p＜0.05). The degree of reduction in lipid levels of mice treated with co-administration of Atv and Nom was less than that of mice treated with Atv alone. In addition, Nom could cause an increased hepatic microsomal CYP3A11 activity significantly, and induce the gene levels and protein expressions of CYP3A11 elevated in mice livers. In conclusion, Nom could up-regulate CYP3A11 activity, thereby impacting on the pharmacokinetic profile and pharmacodynamic effect of Atv. The findings provide more insight for the use risk of these two drugs to treat hyperlipidemia diseases.

Influence of konjac glucomannan and its derivatives on the oral pharmacokinetics of antimicrobial agent in antibiotics cocktails: Keep vigilant on dietary fiber supplement

In this study, konjac glucomannan (KGM) and its derivatives were gavaged as dietary fiber supplements, followed by a single dose of antibiotic cocktail (Abx) containing amoxicillin, neomycin, metronidazole and vancomycin in mice. The effects of dietary fiber on the pharmacokinetics and tissue distribution of each antibiotic were investigated. The results showed that the specific effects of KGM and its derivatives on the absorption, distribution, and elimination of certain antibiotics varied and depended on the nature of the fibers and the characteristics of the antibiotics. Explicitly, the ingestion of KGM and its derivatives enhanced the absorption of metronidazole by 1.7 times and hindered that of amoxicillin by nearly 36 % without affecting the absorption of neomycin sulfate and vancomycin. KGM and its derivatives had no effect on the distribution of amoxicillin and metronidazole, but DKGM and KGM hindered the distributions of neomycin sulfate (from 1.25 h to 1.62 h) and vancomycin (from 0.95 h to 1.14 h), respectively. KGM and its derivatives promoted the elimination of amoxicillin by nearly 38 % while prolonging that of metronidazole by >50 %. KOGM boosted the elimination of neomycin sulfate and vancomycin, but KGM differed from DKGM in acting on the elimination of both.

An eco-friendly ultra-performance liquid chromatography-mass spectrometry method for quantification of rivaroxaban and ticagrelor in rat plasma: grapefruit interactions

Aim: An eco-friendly ultra-performance liquid chromatography-tandem mass spectrometry method was developed to study the pharmacokinetics of rivaroxaban and ticagrelor in rat plasma, utilizing moxifloxacin as an internal standard. The food-drug interaction between grapefruit juice and these drugs was also investigated. Methods: Liquid-liquid extraction was used. A nonporous stationary phase Agilent® Poroshell 120EC C18 column was used with methanol: 0.1% aqueous formic acid (95:5 v/v) as a mobile phase. The detection was performed in multiple reaction monitoring mode using positive electrospray ionization. The method's validation was conducted in accordance with US FDA and European Medicines Agency guidelines. Results & conclusion: Grapefruit juice should be ingested with caution in patients treated with antithrombotic medications as it may increase their plasma concentration, inducing bleeding, and requires close clinical monitoring.

Safety Concerns Related to the Simultaneous Use of Prescription or Over-the-Counter Medications and Herbal Medicinal Products: Survey Results among Latvian Citizens

The use of herbal medicines is increasing worldwide. While the safety profile of many herbal medicines is promising, the data in the literature show important interactions with conventional drugs that can expose individual patients to high risk. The aim of this study was to investigate the experience of the use of herbal medicines and preparations and the risks of interactions between herbal and conventional medicines among Latvian citizens. Data were collected between 2019 and 2021 using a structured questionnaire designed for pharmacy customers in Latvia. Electronic databases such as Drugs.com, Medscape, and European Union herbal monographs were reviewed for the risk of drug interactions and potential side effects when herbal medicines were involved. The survey included 504 respondents. Of all the participants, 77.8% used herbal preparations. Most of the participants interviewed used herbal remedies based on the recommendation of the pharmacist or their own initiative. A total of 38.3% found the use of herbal remedies safe and harmless, while 57.3% of respondents regarded the combination of herbal and regular drugs as unsafe. The identified herbal medicines implicated in the potential risk of serious interactions were grapefruit, St. John's wort, and valerian. As the risks of herb-drug interactions were identified among the respondents, in the future, both pharmacy customers and healthcare specialists should pay more attention to possible herb-drug interactions of over-the-counter and prescription medications.

Nutraceuticals and network pharmacology approach for acute kidney injury: A review from the drug discovery aspect

Acute kidney injury (AKI) has become a global health issue, with ~12 million reports yearly, resulting in a persistent increase in morbidity and mortality rates. AKI pathophysiology is multifactorial involving oxidative stress, mitochondrial dysfunction, epigenetic modifications, inflammation, and eventually, cell death. Hence, therapies able to target multiple pathomechanisms can aid in AKI management. To change the drug discovery framework from "one drug, one target" to "multicomponent, multitarget," network pharmacology is evolving as a next-generation research approach. Researchers have used the network pharmacology approach to predict the role of nutraceuticals against different ailments including AKI. Nutraceuticals (herbal products, isolated nutrients, and dietary supplements) belong to the pioneering category of natural products and have shown protective action against AKI. Nutraceuticals have recently drawn attention because of their ability to provide physiological benefits with less toxic effects. This review emphasizes the nutraceuticals that exhibited renoprotection against AKI and can be used either as monotherapy or adjuvant with conventional therapies to boost their effectiveness and lessen the adverse effects. Additionally, the study sheds light on the application of network pharmacology as a cost-effective and time-saving approach for the therapeutic target prediction of nutraceuticals against AKI.

Stereoisomers of octahydrocurcumin, the hydrogenated metabolites of curcumin, display stereoselective activity on the CYP2E1 enzyme in L-02 cells

As the final hydrogenated metabolite of curcumin, octahydrocurcumin (OHC) exhibits increased powerful bioactivities. The chiral and symmetric chemical structure indicated that there were two OHC stereoisomers, (3R,5S)-octahydrocurcumin (Meso-OHC) and (3S,5S)-octahydrocurcumin ((3S,5S)-OHC), which may induce different effects on metabolic enzymes and bioactivities. Thus, we detected OHC stereoisomers from rat metabolites (blood, liver, urine and feces) after oral administration of curcumin. In addition, OHC stereoisomers were prepared and then their different influences on cytochrome P450 enzymes (CYPs) and UDP-glucuronyltransferases (UGTs) in L-02 cells were tested to explore the potential interaction and different bioactivities. Our results proved that curcumin could be metabolised into OHC stereoisomers first. In addition, Meso-OHC and (3S,5S)-OHC exhibited slight induction or inhibition effects on CYP1A2, CYP2A6, CYP2C8, CYP2C9, CYP3A4 and UGTs. Furthermore, Meso-OHC exhibited more intensive inhibition toward CYP2E1 expression than (3S,5S)-OHC, ascribed to the different mode of binding to the enzyme protein (P < 0.05), which finally induced more effective liver protection effects in acetaminophen-induced L-02 cell injury.

The Self-Administered Use of Complementary and Alternative Medicine (CAM) Supplements and Antioxidants in Cancer Therapy and the Critical Role of Nrf-2-A Systematic Review

Complementary and alternative medicine (CAM) supplements are widely used by cancer patients. Dietary supplements, vitamins and minerals, herbal remedies, and antioxidants are especially popular. In a systematic literature review, 37 studies, each including more than 1000 participants, on CAM, dietary supplement, and vitamin use among cancer patients were identified. Accordingly, cancer patients use antioxidants such as vitamin C (from 2.6% (United Kingdom) to 41.6% (United States)) and vitamin E (from 2.9% (China) to 48% (United States)). Dietary supplements and vitamins are taken for different reasons, but often during conventional cancer treatment involving chemotherapy or radiotherapy and in a self-decided manner without seeking medical advice from healthcare professionals. Drug-drug interactions with dietary supplements or vitamins involving multiple signaling pathways are well described. Since most of the anticancer drugs generate reactive oxygen species (ROS), an adaptive stress response of healthy and malignant cells, mainly driven by the Nrf-2-Keap I network, can be observed. On the one hand, healthy cells should be protected from ROS-overproducing chemotherapy and radiotherapy; on the other hand, ROS production in cancer cells is a "desirable side effect" during anticancer drug treatment. We here describe the paradoxical use of antioxidants and supplements during cancer therapy, possible interactions with anticancer drugs, and the involvement of the Nrf-2 transcription factor.

Drug-Drug Interactions With Over-The-Counter Medicines: Mind the Unprescribed

BACKGROUND

This review provides a summary of the currently available clinical data on drug-drug interactions (DDIs) involving over-the-counter (OTC) medicines. It aims to educate and increase awareness among health care providers and to support decisions in daily practice.

METHODS

An extensive literature search was performed using bibliographic databases available through PubMed.gov. An initial structured search was performed using the keywords "drug-drug-interaction AND (over-the-counter OR OTC)," without further restrictions except for the language. The initial results were screened for all described DDIs involving OTC drugs, and further information was gathered specifically on these drugs using dedicated database searches and references found in the bibliography from the initial hits.

RESULTS

From more than 1200 initial hits (1972-June 2021), 408 relevant publications were screened for DDIs involving OTC drugs, leading to 2 major findings: first, certain types of drug regimens are more prone to DDIs or have more serious DDI-related consequences, such as antiretroviral, anti-infective, and oral anticancer therapies. Second, although most DDIs involve OTC drugs as the perpetrators, some prescription drugs (statins or phosphodiesterase-5 inhibitors) that currently have OTC status can be identified as the victims in DDIs. The following groups were identified to be frequently involved in DDIs: nonsteroidal anti-inflammatory drugs, food supplements, antacids, proton-pump inhibitors, H2 antihistamines, laxatives, antidiarrheal drugs, and herbal drugs.

CONCLUSIONS

The most significant finding was the lack of high-quality evidence for commonly acknowledged interactions. High-quality interaction studies involving different phenotypes in drug metabolism (cytochrome P450) and distribution (transporters) are urgently needed. This should include modern and critical drugs, such as oral anticancer medications and direct oral anticoagulants.

Dietary Inhibitors of CYP3A4 Are Revealed Using Virtual Screening by Using a New Deep-Learning Classifier

CYP3A4 is the main human enzyme responsible for phase I metabolism of dietary compounds, prescribed drugs and xenobiotics, steroid hormones, and bile acids. The inhibition of CYP3A4 activity might impair physiological mechanisms, including the endocrine system and response to drug admission. Here, we aimed to discover new CYP3A4 inhibitors from food and dietary supplements. A deep-learning model was built that classifies compounds as either an inhibitor or noninhibitor, with a high specificity of 0.997. We used this classifier to virtually screen ∼60,000 dietary compounds. Of the 115 identified potential inhibitors, only 31 were previously suggested. Many herbals, as predicted here, might cause impaired metabolism of drugs, and endogenous hormones and bile acids. Additionally, by applying Lipinski's rules of five, 17 compounds were also classified as potential intestine local inhibitors. New CYP3A4 inhibitors predicted by the model, bilobetin and picropodophyllin, were assayed in vitro.

Influence of methylxanthines isolated from Bancha green tea on the pharmacokinetics of sildenafil in rats

BACKGROUND

Sildenafil is used to treat erectile dysfunction and pulmonary arterial hypertension and is metabolized in the liver mainly by CYP3A4, thus co-administration with drugs or herbal extracts that affect CYP3A4 activity may lead to drug-drug or drug-herb interactions, respectively. The aim of the present study was to evaluate the influence of single and multiple oral doses of methylxanthine fraction, isolated from Bancha green tea leaves on the pharmacokinetics of sildenafil in rats.

METHODS

Rats were given sildenafil alone as well as simultaneously with methylxanthines or ketoconazole. The plasma concentrations of sildenafil were measured with high-performance liquid chromatography method with ultraviolet detection. The pharmacokinetic parameters of sildenafil were calculated by non-compartmental analysis.

RESULTS

Concomitant use of sildenafil with a single oral dose of methylxanthines resulted in a decrease in C_max (p > 0.05), AUC_0-t (p < 0.05) and AUC_0-inf (p < 0.05), while the administration of sildenafil after methylxanthines pretreatment resulted in an increase in C_max (p < 0.0001), AUC_0-t (p < 0.0001) and AUC_0-inf (p < 0.001) compared to the sildenafil group. After co-administration of sildenafil and ketoconazole, a significant increase in C_max, AUC_0-t and AUC_0-inf was observed in both of the experiments.

CONCLUSION

Drug-herb interactions were observed when sildenafil was co-administered with Bancha methylxanthines in rats. Further in vivo studies about the potential drug interactions between sildenafil and methylxanthines, especially caffeine, are needed to clarify mechanisms underlying the observed changes in sildenafil pharmacokinetics.

A novel graph mining approach to predict and evaluate food-drug interactions

Food-drug interactions (FDIs) arise when nutritional dietary consumption regulates biochemical mechanisms involved in drug metabolism. This study proposes FDMine, a novel systematic framework that models the FDI problem as a homogenous graph. Our dataset consists of 788 unique approved small molecule drugs with metabolism-related drug-drug interactions and 320 unique food items, composed of 563 unique compounds. The potential number of interactions is 87,192 and 92,143 for disjoint and joint versions of the graph. We defined several similarity subnetworks comprising food-drug similarity, drug-drug similarity, and food-food similarity networks. A unique part of the graph involves encoding the food composition as a set of nodes and calculating a content contribution score. To predict new FDIs, we considered several link prediction algorithms and various performance metrics, including the precision@top (top 1%, 2%, and 5%) of the newly predicted links. The shortest path-based method has achieved a precision of 84%, 60% and 40% for the top 1%, 2% and 5% of FDIs identified, respectively. We validated the top FDIs predicted using FDMine to demonstrate its applicability, and we relate therapeutic anti-inflammatory effects of food items informed by FDIs. FDMine is publicly available to support clinicians and researchers.

Interactions between Food and Drugs, and Nutritional Status in Renal Patients: A Narrative Review

Drugs and food interact mutually: drugs may affect the nutritional status of the body, acting on senses, appetite, resting energy expenditure, and food intake; conversely, food or one of its components may affect bioavailability and half-life, circulating plasma concentrations of drugs resulting in an increased risk of toxicity and its adverse effects, or therapeutic failure. Therefore, the knowledge of these possible interactions is fundamental for the implementation of a nutritional treatment in the presence of a pharmacological therapy. This is the case of chronic kidney disease (CKD), for which the medication burden could be a problem, and nutritional therapy plays an important role in the patient’s treatment. The aim of this paper was to review the interactions that take place between drugs and foods that can potentially be used in renal patients, and the changes in nutritional status induced by drugs. A proper definition of the amount of food/nutrient intake, an adequate definition of the timing of meal consumption, and a proper adjustment of the drug dosing schedule may avoid these interactions, safeguarding the quality of life of the patients and guaranteeing the effectiveness of drug therapy. Hence, a close collaboration between the nephrologist, the renal dietitian, and the patient is crucial. Dietitians should consider that food may interact with drugs and that drugs may affect nutritional status, in order to provide the patient with proper dietary suggestions, and to allow the maximum effectiveness and safety of drug therapy, while preserving/correcting the nutritional status.

OUP accepted manuscript

Background

Complementary medicines (CM) are frequently used by patients with cancer. Controversy exists over the effectiveness and risk that CM may add to conventional cancer therapy. The incidence of CM use among patients enrolled in phase III clinical trials is unknown.

Methods

Medication lists from 6 international phase III clinical trials were retrospectively reviewed to identify patients using CM. Patients had metastatic breast, colorectal, or lung cancers. Quality of life, adverse events, overall survival, and progression-free survival were compared between CM users and non-users. Baseline differences between groups were adjusted with propensity score matching groups.

Results

Seven hundred and six of 3446 patients (20.5%) used at least one CM. CM use was highest among patients with breast cancer (35.6%). CM users had more favorable baseline prognostic factors (ECOG 0-1, non-smoking status, younger age, and fewer metastases). CM use was associated with lower rates of adverse events (50% vs. 62%, P = .002) and quality of life was similar between both groups. After adjustment with propensity score matching, CM use was also associated with longer overall survival in patients with lung cancer (adjusted hazard ratio 0.80, 95%CI, 0.68-0.94, P =.0054). However, several key control variables like EGFR status were not available.

Conclusion

One in 5 patients in phase III clinical trials report using CM. CM was not associated with worse cancer-specific outcomes. However, CM users had more favorable baseline prognostic factors, and likely other confounders that may have contributed to improved outcomes observed in the lung cohort. Physicians should monitor for CM use and potential interactions with clinical trial drugs.

In Vitro and In Vivo Assessment of Atemoya Fruit (Annona atemoya) for Food-Drug Interactions

BACKGROUND AND OBJECTIVES

Atemoya (Annona atemoya) is increasingly being consumed worldwide because of its pleasant taste. However, only limited information is available concerning possible atemoya-drug interactions. In the present study, the issue of whether atemoya shows food-drug interactions with substrate drugs of the major drug-metabolizing cytochrome P450s (i.e., CYP1A2, CYP2C9, and CYP3A) is addressed.

METHODS

The ability of atemoya juice to inhibit the activities of phenacetin O-deethylase (CYP1A2), diclofenac 4'-hydroxylase (CYP2C9), and midazolam 1'-hydroxylase (CYP3A) was examined in vitro using human and rat liver microsomes. The in vivo pharmacokinetics of phenacetin and metabolites derived from it in rats when atemoya juice or fluvoxamine (a CYP1A2 inhibitor) was preadministered were also investigated.

RESULTS

Atemoya juice significantly inhibited CYP1A2 activity in human liver microsomes, but not the activities of CYP2C9 and CYP3A. In spite of this inhibition, preadministration of atemoya had no effect on the pharmacokinetics of phenacetin, a CYP1A2 substrate, in rats. Meanwhile, preadministration of fluvoxamine significantly extended the time needed for the elimination of phenacetin, possibly due to the inhibition of CYP1A2. This suggests that the intake of an excess amount of atemoya juice is necessary to cause a change in the pharmacokinetics of phenacetin when the IC₅₀ values for CYP1A2 inhibition by atemoya and fluvoxamine are taken into account.

CONCLUSION

The results indicate that a daily intake of atemoya would not change the pharmacokinetics of CYP1A2 substrates such as phenacetin as well as CYP2C9- and CYP3A-substrate drugs.

Pharmacokinetic interactions: The effects of selected herbal extracts on permeation of P-glycoprotein substrate drugs across excised pig intestinal tissue

Introduction: There is growing concern that co-administered herbal medicines may alter the pharmacokinetics and, therefore, the efficacy and toxicity of Western drugs. The aim of this study was to investigate the potential membrane permeation modulating effects of four herbal extracts, i.e., Harpagophytum procumbens, Hoodia gordonii, Leonotis leonurus, and Vitis vinifera on a model compound, Rhodamine 123 (RH-123). Methods: An in vitro permeation model, i.e., excised pig intestinal tissue, mounted to test chambers in a Sweetana-Grass diffusion apparatus, was used to measure the bi-directional transport of RH-123 in the presence and in the absence of four herbal extracts. The concentration of transported RH-123 in each sample was determined by means of fluorescence spectroscopic analysis. The integrity of the mounted jejunum tissue during experimentation was confirmed by measuring the permeation of Lucifer Yellow through these membranes. Trans-epithelial electrical resistance (TEER) of the mounted membranes was also measured at the onset and termination of each experiment to monitor whether tight junction modulation occurred. Results: H. procumbens extract increased the secretory transport of RH-123, indicative of the induction of P-glycoprotein (P-gp) mediated efflux. H. gordonii extract also increased RH-123’s absorptive transport, coupled with a subsequent decrease in its secretory transport, indicating the P-gp related efflux inhibition. Contrary, L. leonurus extract reduced RH-123’s absorptive transport, accompanied by an increase in its secretory transport. V. vinifera seed extract, however, increased both the absorptive and secretory transport of RH-123. A reduction in TEER was observed in the presence of V. vinifera extract, indicating the modulation of tight junction integrity. Conclusion: The ex vivo pharmacokinetics interactions recorded in the current study suggest that the co-administration of herbal medicines could alter the extent of membrane permeation of Western drugs.

Metabolism‑related pharmacokinetic drug‑drug interactions with poly (ADP‑ribose) polymerase inhibitors (Review)

Poly (ADP‑ribose) polymerase (PARP) inhibitors, including olaparib, niraparib, rucaparib, talazoparib and veliparib, have emerged as one of the most exciting new treatments for solid tumors, particularly in patients with breast‑related cancer antigen 1/2 mutations. Oral administration is convenient and shows favorable compliance with the majority of patients, but it may be affected by numerous factors, including food, metabolic enzymes and transporters. These interactions may be associated with serious adverse drug reactions or may reduce the treatment efficacy of PARP inhibitors. In fact, numerous pharmacokinetic (PK)‑based drug‑drug interactions (DDIs) involve the metabolism of PARP inhibitors, particularly those metabolized via cytochrome P450 enzymes. The present review aims to characterize and summarize the metabolism‑related PK‑based DDIs of PARP inhibitors, and to provide specific recommendations for reducing the risk of clinically significant DDIs.

Alcohol-medication interactions: A systematic review and meta-analysis of placebo-controlled trials

Alcohol and other xenobiotics may limit the therapeutic effects of medications. We aimed at investigating alcohol-medication interactions (AMI) after the exclusion of confounding effects related to other xenobiotics. We performed a systematic review and meta-analysis of controlled studies comparing the effects induced by alcohol versus placebo on pharmacodynamic and/or pharmacokinetic parameters of approved medications. Certainty in the evidence of AMI was assessed when at least 3 independent studies and at least 200 participants were available. We included 107 articles (3097 participants): for diazepam, cannabis, opioids, and methylphenidate, we found significant AMI and enough data to assign the certainty of evidence. Alcohol consumption significantly increases the peak plasma concentration of diazepam (low certainty; almost 290 participants), cannabis (high certainty; almost 650 participants), opioids (low certainty; 560 participants), and methylphenidate (moderate certainty; 290 participants). For most medications, we found some AMI but not enough data to assign them the certainty grades; for some medications, we found no differences between alcohol and placebo in any outcomes evaluated. Our results add further evidence for interactions between alcohol and certain medications after the exclusion of confounding effects related to other xenobiotics. Physicians should advise patients who use these specific medications to avoid alcohol consumption. Further studies with appropriate control groups, enough female participants to investigate sex differences, and elderly population are needed to expand our knowledge in this field. Short phrases suitable for indexing terms.

Over-The-Counter Remedies in Older Adults: Patterns of Use, Potential Pitfalls, and Proposed Solutions

Over-the-counter (OTC) products such as pharmaceuticals, dietary supplements, vitamins, and herbal remedies are widely available and copiously used by older adults for health maintenance and symptom management. Owing to physiology, multimorbidity, and polypharmacy, this population is particularly vulnerable to inappropriate use of OTC products, adverse effects, and drug interactions. While OTC pharmaceuticals are bound by FDA-approved standards, dietary supplements are regulated differently, resulting in variable quality and increased possibility for adulteration. Internationally, standards for OTC products vary widely. Accessible educational information, improved provider-patient communication, and revision of regulatory policy could improve safety for older adult users of OTC products.

Food supplement vitamins, minerals, amino-acids, fatty acids, phenolic and alkaloid-based substances: An overview of their interaction with drugs

Food supplements are a widespread group of products ingested as a diet complement, whose consumption has recently skyrocketed due to the consumers' concern with their well-being. Among food supplements, vitamin- and mineral-based ones are the top sellers, and the demand of others, such as those containing polyphenols, is increasing. Owing to their alleged natural characteristics, consumers take the safety of food supplements for granted, and use them even when taking medicines. Thus, their potential interactions with drugs have been sparsely evaluated. This manuscript aims to bring forth an up-to-date overview of the most important knowledge involving the interactions between food supplements and drugs, relevant to be aware by nutritionists and other healthcare professionals. To this end, an extensive bibliographic review was conducted focusing on peer reviewed data from experimental in vivo evidence and clinical studies whenever major clinical interactions have been reported. Elder people and polymedicated or chronic patients are especially vulnerable to the therapeutic ineffectiveness and toxicity caused by these types of interactions. Drugs used to treat cardiovascular, autoimmune, nervous, and oncological diseases are commonly involved in important clinical interactions with food supplements, many with a narrow therapeutic margin.

Fed or fasted state for oral therapies in breast cancer treatment? A comprehensive review of clinical practice recommendations

In the last decades several anti-cancer drugs have been developed to treat patients with breast cancer, many of them orally administered, with ongoing efforts to substitute parenteral drugs with oral therapy. The latter is attractive because of its convenience and ease of administration, finally improving quality of life. The drawback of oral administration is that exposure to the drug is affected by different factors and the high variability, combined with the relatively narrow therapeutic index of most of these agents, would predispose some individuals to risk for treatment inefficacy or increase toxicity. Among these factors, food plays a central role since it can influence the pharmacokinetic profile of several drugs. Consequently, health care providers and patients should be aware of possible interaction to optimize treatment. In this review a systematic evaluation of package inserts and literature have been performed to analyse the effect of fed or fasted state on pharmacokinetic of all oral drugs currently approved for breast cancer, offering clear recommendations for their use daily practice.

Mechanisms and interactions in concomitant use of herbs and warfarin therapy: An updated review

This review is an updated and expanded version published in this journal in 2016. Warfarin pharmacotherapy is extremely complex, since in addition to being a low therapeutic index drug, it does not follow the dose-response pattern and has characteristics that predispose the occurrence of interactions, such as high binding rate to plasma proteins, metabolization by cytochrome P450 enzymes, further to acting in the complex process of blood coagulation, platelet activation, and inflammation. For these reasons, warfarin has great potential for interaction with drugs, foods, and herbal medicines. Herb-warfarin interactions, however, are still not very well studied; thus, the objective of this update is to present new information on the subject aiming to provide a scientific basis to help health professionals in the clinical management of these interactions. A literature review was performed from May to June 2021 in multiple databases and articles published in 2016 to 2021 were included. A total of 59 articles describing 114 herbal medicines were reported to interact with warfarin. Of the plants mentioned, 84% had the potential to increase warfarin effect and the risk of bleeding. Targets possibly involved in these interactions include the processes of blood coagulation, platelet activation, and inflammation, in addition to the pharmacokinetics and pharmacodynamics of warfarin. Despite these alarming numbers, however, the clinical management of interactions is known to be effective. Thus, it is important that the use of these herbal medicines be done with caution in anticoagulated patients and that studies of herb-drug interactions be encouraged in order to generate information to support the clinical management of patients.

Prevalence of drug-drug interactions in sarcoma patients: key role of the pharmacist integration for toxicity risk management

BACKGROUND

The risk of drug-drug interactions (DDI) has become a major issue in cancer patients. However, data in sarcoma patients are scarce. We aimed to evaluate the frequency and the factors associated with DDI with antitumor treatments, and to evaluate the impact of a pharmacist evaluation before anticancer treatment.

PATIENTS AND METHODS

We performed a retrospective review of consecutive sarcoma patients starting chemotherapy (CT) or Tyrosine kinase inhibitor (TKI). A pharmacist performed medication reconciliation and established an early toxicity risk assessment. Potential DDI with antitumor drugs were identified using Micromedex electronic software.

RESULTS

One hundred and twenty-two soft-tissue and 80 bone sarcoma patients (103 males, median age 50 years,) were included before CT (86%) or TKI (14%). The median number of medications was 3; 34 patients (22% of patients with medication reconciliation) reported complementary medicine use. 37 potential DDI classified as major, were identified (12% of the 243 pre-therapeutic assessments). In multivariate analysis, TKI (p < 0.0001), proton pump inhibitor (p = 0.026) and antidepressant (p < 0.001) were identified as risk factors of DDI (p < 0.02). Only marital status (p = 0.003) was associated with complementary medicine use. A pharmacist performed 157 medication reconciliations and made 71 interventions among 59 patients (37%). In multivariate analysis, factors associated with pharmacist intervention were: complementary medicines (p = 0.004), drugs number (p = 0.005) and treatment with TKI (p = 0.0002) CONCLUSIONS: Clinical interventions on DDI are more frequently required among sarcoma patients treated with TKI than CT. Multidisciplinary risk assessment including a medication reconciliation by a pharmacist could be crucial to prevent DDI with TKI.

Nutraceuticals: Transformation of Conventional Foods into Health Promoters/Disease Preventers and Safety Considerations

Nutraceuticals are essential food constituents that provide nutritional benefits as well as medicinal effects. The benefits of these foods are due to the presence of active compounds such as carotenoids, collagen hydrolysate, and dietary fibers. Nutraceuticals have been found to positively affect cardiovascular and immune system health and have a role in infection and cancer prevention. Nutraceuticals can be categorized into different classes based on their nature and mode of action. In this review, different classifications of nutraceuticals and their potential therapeutic activity, such as anti-cancer, antioxidant, anti-inflammatory and anti-lipid activity in disease will be reviewed. Moreover, the different mechanisms of action of these products, applications, and safety upon consumers including current trends and future prospect of nutraceuticals will be included.

Petroselinum crispum, a commonly consumed food, affects sirolimus level in a renal transplant recipient: a case report

Sirolimus is an immunosuppressive drug used to prevent graft rejection. Therapeutic drug monitoring is required as with other immunosuppressive drugs. Previous studies have shown the interactions between sirolimus and drugs that affect the activity of cytochrome P450 3A4 and P-glycoprotein. There is an increasing tendency for the use of herbal remedies in many countries. Medicinal herbs are rich sources of natural bioactive compounds that could interact with drugs. Parsley, Petroselinum crispum, is a food, spice, and also a medicinal herb. We report a case of a renal transplant recipient who had a supratherapeutic blood level of sirolimus due to consuming excessive parsley to highlight a possible herb–drug interaction. This is the first case report describing sirolimus–parsley interaction. Herb–drug interactions are especially important for drugs with a narrow therapeutic window. For this reason, healthcare professionals should question all patients, especially transplant patients, about the use of herbs or herbal products and report interactions.

The perception of Jordanian population towards concomitant administration of food, beverages and herbs with drugs and their possible interactions: A cross-sectional study

BACKGROUND

Many people are used to administering their drugs with food, beverages or herbs. These substances may contain chemicals that interfere with the prescribed drugs and could potentially lead to changes in their efficacy or safety, and could result in alterations in their pharmacokinetic properties.

OBJECTIVE

To assess the extent of the perception and consumption of food, beverages and herbs alongside conventional drugs, along with their potential interactions, specifically in Jordanian society.

METHODS

A descriptive cross-sectional survey was conducted in Jordan (20 April - 5 May 2020). The survey was developed using Google Forms, then validated and distributed via social media platforms. Data were analysed using Statistical Package for Social Sciences-24.

MAIN OUTCOME MEASURE

Use and perception of food, beverages, herbs and how they interact with drugs among Jordanians.

RESULTS

Of all the participants (n = 789), 77.8% were females, 46.2% were 50-year-olds, 69.7% were married, 70.8% were medically insured, and 51.1% had bachelor's degrees. 70% of the study participants reported use of medicinal plants. About 66% of participants agreed that medicinal plants or herbs could treat diseases and 58.6% thought that medications could interact with drugs. In general, the participants' knowledge about food/beverage/herb-drug interactions was considered poor. However, a linear regression analysis showed that the level of knowledge was significantly affected (P < .05) by gender, marital status, social status, educational level and employment sector.

CONCLUSION

Jordanians have a positive perception towards herbs and their ability to treat diseases. However, their knowledge about food/beverage-drug interactions was poor. There is therefore a need to enhance the community awareness of food/beverage/herb-drug interactions.

Are Nutraceuticals Beneficial in Chronic Kidney Disease?

Chronic kidney disease (CKD) is a worldwide health problem in which prevalence is constantly rising. The pathophysiology of CKD is complicated and has not been fully resolved. However, elevated oxidative stress is considered to play a vital role in the development of this disease. CKD is also thought to be an inflammatory disorder in which uremic toxins participate in the development of the inflammatory milieu. A healthy, balanced diet supports the maintenance of a good health status as it helps to reduce the risk of the development of chronic diseases, including chronic kidney disease, diabetes mellitus, and hypertension. Numerous studies have demonstrated that functional molecules and nutrients, including fatty acids and fiber as well as nutraceuticals such as curcumin, steviol glycosides, and resveratrol not only exert beneficial effects on pro-inflammatory and anti-inflammatory pathways but also on gut mucosa. Nutraceuticals have attracted great interest recently due to their potential favorable physiological effects on the human body and their safety. This review presents some nutraceuticals in which consumption could exert a beneficial impact on the development and progression of renal disease as well cardiovascular disease.

Patient Suffering in Chronic Digestive Diseases: Will Primary Care-Specialist Collaboration With Effective Interactive Communication and Integrative Medicine in the Plan of Care Improve Quality of Life?

Acute and chronic digestive diseases are causing increased burden to patients and are increasing the United States health care spending. The purpose of this case report was to present how nonconfirmatory and conflicting diagnoses led to increased burden and suffering for a patient thus affecting quality of life. There were many physician visits and multiple tests performed on the patient. However, the primary care physician and specialists could not reach a confirmatory diagnosis. The treatment plans did not offer relief of symptoms, and the patient continues to experience digestive symptoms, enduring this burden for over 2 years. The central theme of this paper is to inform health care providers the importance of utilizing evidence-based primary care specialist collaboration models for better digestive disease outcomes. Consistent with patient’s experience, the authors propose to pilot/adopt the integrative health care approaches that are proven effective for treating digestive diseases.

In vitro antagonistic inhibitory effects of palm seed crude oils and their main constituent, lauric acid, with oxacillin in Staphylococcus aureus

Infections caused by Staphylococcus aureus are a serious global threat, and with the emergence of antibiotic resistance, even more difficult to treat. One of the possible complications in antistaphylococcal therapy represents negative interactions of antibiotics with food. In this study, the in vitro interaction between oxacillin and crude palm seed oil from Astrocaryum vulgare, Cocos nucifera, and Elaeis guineensis against nine strains of S. aureus was determined using the checkerboard method. Lauric acid was identified as a major constituent of all tested oils by gas chromatography. The results showed strong concentration dependent antagonistic interactions between palm oils and oxacillin with values of fractional inhibitory concentrations indices ranging from 4.02 to 8.56 at concentrations equal or higher than 1024 µg/mL of the tested oils. Similarly, lauric acid in combination with oxacillin produced antagonistic action with fractional inhibitory concentration indices ranging from 4.01 to 4.28 at 1024 µg/mL. These findings suggest that interference between oxacillin and palm oils and their constituents can negatively affect the treatment of staphylococcal infections in humans and other animals.

Food-Drug Interactions with Fruit Juices

Fruit juices contain a large number of phytochemicals that, in combination with certain drugs, can cause food–drug interactions that can be clinically significant and lead to adverse events. The mechanisms behind such interactions are in most cases related to phytochemical interference with the activity of cytochrome P450 metabolizing enzymes (CYPs) or drug transporters. Moreover, alterations in their activity can have a clinical relevance if systemic exposure to the drug is decreased or increased, meaning that the pharmacological drug effects are suboptimal, or the drug will cause toxicity. In general, the common pharmacokinetic parameters found to be altered in food–drug interactions regarding fruit juices are the area under the concentration–time curve, bioavailability, and maximum plasma concentration. In most cases, the results from the drug interaction studies with fruit juices provide only limited information due to the small number of subjects, which are also healthy volunteers. Moreover, drug interactions with fruit juices are challenging to predict due to the unknown amounts of the specific phytochemicals responsible for the interaction, as well as due to the inter-individual variability of drug metabolism, among others. Therefore, this work aims to raise awareness about possible pharmacological interactions with fruit juices.

Flavoured water consumption alters pharmacokinetic parameters and increases exposure of erlotinib and gefitinib in a preclinical study using Wistar rats

Background

Erlotinib (ERL) and Gefitinib (GEF) are considered first line therapy for the management of non-small cell lung carcinoma (NSCLC). Like other tyrosine kinase inhibitors (TKIs), ERL and GEF are mainly metabolized by the cytochrome P450 (CYP450) CYP3A4 isoform and are substrates for transporter proteins with marked inter-/intra-individual pharmacokinetic (PK) variability. Therefore, ERL and GEF are candidates for drug-drug and food-drug interactions with a consequent effect on drug exposure and/or drug-related toxicities. In recent years, the consumption of flavoured water (FW) has gained in popularity. Among multiple ingredients, fruit extracts, which might constitute bioactive flavonoids, can possess an inhibitory effect on the CYP450 enzymes or transporter proteins. Therefore, in this study we investigated the effects of different types of FW on the PK parameters of ERL and GEF in Wistar rats.

Methods

ERL and GEF PK parameters in different groups of rats after four weeks consumption of different flavours of FW, namely berry, peach, lime, and pineapple, were determined from plasma drug concentrations using ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS).

Results

Data indicated that tested FWs altered the PK parameters of both ERL and GEF differently. Lime water had the highest impact on most of ERL and GEF PK parameters, with a significant increase in C_max (95% for ERL, 58% for GEF), AUC_0-48 (111% for ERL, 203% for GEF), and AUC_0-∞ (200% for ERL, 203% for GEF), along with a significant decrease in the apparent oral clearance of both drugs (65% for ERL, 67% for GEF). The order by which FW affected the PK parameters for ERL and GEF was as follows: lime > pineapple > berry > peach.

Conclusion

The present study indicates that drinking FW could be of significance in rats receiving ERL or GEF. Our results indicate that the alteration in PKs was mostly recorded with lime, resulting in an enhanced bioavailability, and reduced apparent oral clearance of the drugs. Peach FW had a minimum effect on the PK parameters of ERL and no significant effect on GEF PKs. Accordingly, it might be of clinical importance to evaluate the PK parameters of ERL and GEF in human subjects who consume FW while receiving therapy.

Simultaneous determination of vitamin B6 and catechins in dietary supplements by ZIC-HILIC chromatography and their antioxidant interactions

Hydrophilic interaction liquid chromatography coupled to mass spectrometry was employed for simultaneous determination of vitamin B6 and catechins in dietary supplements. The obtained results clearly shows the potential of the application of alcohol eluent (instead mainly used acetonitrile) as a component of an with zwitterionic stationary phase. The limits of detection on ZIC-HILIC column were 0.01 mg/L for catechins and vitamins B (only for pyridoxal phosphate was 0.10 mg/L). The investigations between green tea extract (GTE) and vitamin B were also evaluated using isobolographic analysis as well as the interaction indexes. Antioxidant activities of single components and their mixtures were determined by DPPH assay. It was found that the mixtures of GTE and vitamin B acted synergistically. In comparison to GTE alone, faster DPPH radical bleaching of the mixtures was observed in the presence of different forms of vitamin B6 (pyridoxine, pyridoxal, or pyridoxal phosphate), particularly for pyridoxal.

Peripheral Opioid Receptor Antagonists for Opioid-Induced Constipation: A Primer on Pharmacokinetic Variabilities with a Focus on Drug Interactions

Opioid analgesics remain a treatment option for refractory acute and chronic pain, despite their potential risk for abuse and adverse events (AEs). Opioids are associated with several common AEs, but the most bothersome is opioid-induced constipation (OIC). OIC is often overlooked but has the potential to affect patient quality of life, increase associated symptom burden, and impede long-term opioid compliance. The peripherally acting µ-receptor antagonists (PAMORAs) are a class of drugs that include methylnaltrexone, naloxegol, and naldemedine. Collectively, each is approved for the treatment of OIC. PAMORAs work peripherally in the gastrointestinal tract, without impacting the central analgesic effects of opioids. However, each has unique pharmacokinetic properties that may be impacted by coadministered drugs or food. This review focuses on important metabolic and pharmacokinetic principals that are pertinent to drug interactions involving µ-opioid receptor antagonists prescribed for OIC. It highlights subtle differences among the PAMORAs that may have clinical significance. For example, unlike naloxegol or naldemedine, methylnaltrexone is not a substrate for CYP3A4 or p-glycoprotein; therefore, its plasma concentration is not altered when coadministered with concomitant medications that are CYP3A4 or p-glycoprotein inducers or inhibitors. With a better understanding of pharmacokinetic nuances of each PAMORA, clinicians will be better equipped to identify potential safety and efficacy considerations that may arise when PAMORAs are coadministered with other medications.

Comparison of eight screening tools to detect interactions between herbal supplements and oncology agents

INTRODUCTION

Patients with cancer are increasingly using herbal supplements, unaware that supplements can interact with oncology treatment. Herb-drug interaction management is critical to ensure optimal treatment outcomes. Several screening tools exist to detect drug-drug interactions, but their performance to detect herb-drug interactions is not known. This study compared the performance of eight drug-drug interaction screening tools to detect herb-drug interaction with anti-cancer agents.

METHODS

The herb-drug interaction detection performance of four subscription (Micromedex, Lexicomp, PEPID, Facts & Comparisons) and free (Drugs.com, Medscape, WebMD, RxList) drug-drug interaction tools was assessed. Clinical relevance of each herb-drug interaction was determined using Natural Medicine and each drug-drug interaction tool. Descriptive statistics were used to calculate sensitivity, specificity, positive predictive value, and negative predictive value. Linear regression was used to compare performance between subscription and free tools.

RESULTS

All tools had poor sensitivity (<0.20) for detecting herb-drug interaction. Lexicomp had the highest positive predictive value (0.98) and best overall performance score (0.54), while Medscape was the best performing free tool (0.52). The worst subscription tools were as good as or better than the best free tools, and as a group subscription tools outperformed free tools on all metrics. Using an average subscription tool would detect one additional herb-drug interaction for every 10 herb-drug interactions screened by a free tool.

CONCLUSION

Lexicomp is the best available tool for screening herb-drug interaction, and Medscape is the best free alternative; however, the sensitivity and performance for detecting herb-drug interaction was far lower than for drug-drug interactions, and overall quite poor. Further research is needed to improve herb-drug interaction screening performance.

Use of Herbal Medicine by Pregnant Women: What Physicians Need to Know

About 80% of the consumers worldwide use herbal medicine (HMs) or other natural products. The percentage may vary significantly (7%-55%) among pregnant women, depending upon social status, ethnicity, and cultural traditions. This manuscript discusses the most common HMs used by pregnant women, and the potential interactions of HMs with conventional drugs in some medical conditions that occur during pregnancy (e.g., hypertension, asthma, epilepsy). It also includes an examination of the characteristics of pregnant HM consumers, the primary conditions for which HMs are taken, and a discussion related to the potential toxicity of HMs taken during pregnancy. Many cultures have used HMs in pregnancy to improve wellbeing of the mother and/or baby, or to help decrease nausea and vomiting, treat infection, ease gastrointestinal problems, prepare for labor, induce labor, or ease labor pains. One of the reasons why pregnant women use HMs is an assumption that HMs are safer than conventional medicine. However, for pregnant women with pre-existing conditions like epilepsy and asthma, supplementation of conventional treatment with HMs may further complicate their care. The use of HMs is frequently not reported to healthcare professionals. Providers are often not questioning HM use, despite little being known about the HM safety and HM-drug interactions during pregnancy. This lack of knowledge on potential toxicity and the ability to interact with conventional treatments may impact both mother and fetus. There is a need for education of women and their healthcare professionals to move away from the idea of HMs not being harmful. Healthcare professionals need to question women on whether they use any HMs or natural products during pregnancy, especially when conventional treatment is less efficient and/or adverse events have occurred as herbal-drug interactions could be the reason for these observations. Additionally, more preclinical and clinical studies are needed to evaluate HM efficacy and toxicity.

Phytofabrication of Nanoparticles as Novel Drugs for Anticancer Applications

Cancer is one of the foremost causes of death globally and also the major stumbling block of increasing life expectancy. Although the primary treatment of surgical resection, chemotherapy, and radiotherapy have greatly reduced the mortality of cancer, the survival rate is still low because of the metastasis of tumor, a range of adverse drug reactions, and drug resistance. For all this, it is relevant to mention that a growing amount of research has shown the anticarcinogenic effect of phytochemicals which can modulate the molecular pathways and cellular events include apoptosis, cell proliferation, migration, and invasion. However, their pharmacological potential is hindered by their low water solubility, low stability, poor absorption, and rapid metabolism. In this scenario, the development of nanotechnology has created novel formulations to maximize the potential use of phytochemicals in anticancer treatment. Nanocarriers can enhance the solubility and stability of phytochemicals, prolong their half-life in blood and even achieve site-targeting delivery. This review summarizes the advances in utilizing nanoparticles in cancer therapy. In particular, we introduce several applications of nanoparticles combined with apigenin, resveratrol, curcumin, epigallocatechin-3-gallate, 6-gingerol, and quercetin in cancer treatment.

Reviewing the mechanisms of natural product-drug interactions involving efflux transporters and metabolic enzymes

The World Health Organization (WHO) and other worldwide health agencies have recently taken initiatives to encourage the use of traditional medicine and/or complementary/alternative medicine in order to promote well-being and public health. In this way, one of the WHO's concerns is the safe use of these therapies. Phytotherapy is a strategy consisting of the use of medicinal plants (MP) and/or herbal medicinal products (HMP) for medicinal purposes. The use of phytotherapy concomitantly with drugs may cause interactions compromising the expected pharmacological action or generating toxic effects. These interactions are complex processes that may occur with multiple medications targeting different metabolic pathways, and involving different compounds present in MP and HMP. Thus, the aim of this review was to summarize the main MP- and HMP-drug interactions that involve specific transporters (P-glycoprotein and BCRP) and CYP450 enzymes (CYP3A4 and CYP2D6), which play relevant roles in the mechanisms of interactions. Firstly, multiple databases were used to search studies describing in vitro or in vivo MP and HMP-drug interactions and, after that, a systematic note-taking and appraisal of the literature was conducted. It was observed that several MP and HMP, metabolic pathways and transcription factors are involved in the transporters and enzymes expression or in the modulation of their activity having the potential to provide such interactions. Thus, the knowledge of MP- and HMP-drug interaction mechanisms could contribute to prevent harmful interactions and can ensure the safe use of these products to help the establishment of the therapeutic planning in order to certify the best treatment strategy to be used.

Pharmacokinetic Interactions between Cardiovascular Medicines and Plant Products

The growing use of plant products among patients with cardiovascular pharmacotherapy raises the concerns about their potential interactions with conventional cardiovascular medicines. Plant products can influence pharmacokinetics or/and pharmacological activity of coadministered drugs and some of these interactions may lead to unexpected clinical outcomes. Numerous studies and case reports showed various pharmacokinetic interactions that are characterized by a high degree of unpredictability. This review highlights the pharmacokinetic clinically relevant interactions between major conventional cardiovascular medicines and plant products with an emphasis on their putative mechanisms, drawbacks of herbal products use, and the perspectives for further well-designed studies.

Use of complementary medicine products: a nationally representative cross-sectional survey of 2019 Australian adults

OBJECTIVES

To provide a contemporary description of complementary medicine (CM) product use in Australia.

DESIGN

Cross-sectional survey.

SETTING

Online.

PARTICIPANTS

A nationally representative sample (n=2019) of the Australian adult population.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes measures included the use and type of CM products used, and source of recommendation. Secondary measures included disclosure of CM product use to health practitioners, concomitant use of pharmaceuticals and predictors of use.

RESULTS

Prevalence of CM product use was 50.3%, with the most frequently used being vitamin and mineral supplements (VMSs; 47.8%) and homoeopathic medicines the least used (6.8%). A majority of respondents using CM products were also using pharmaceutical products, and small but significant associations were found between the use of CM products and pharmaceuticals (p<0.05). Small statistically significant associations were found between use of vitamin products and disclosure of use to general practitioners (GPs; Cramer's V=0.13, p=0.004) and hospital doctors (Cramer's V=0.11, p=0.04), and between use of herbal medicines and disclosure to both GPs (Cramer's V=0.11, p=0.02) and hospital doctors (Cramer's V=0.12, p=0.03). Women, those with higher education and those with no private health insurance were more likely to use CM products (p<0.05), while those without chronic conditions were less likely to use CM products (p<0.05) (χ2(29)=174.70, p<0.001).

CONCLUSIONS

The number of Australians using CM products has remained relatively stable and substantial for nearly two decades. The majority of CM use relates to VMSs. Given the number of Australians using both CM products and pharmaceutical medicines, it is important to evaluate the potential clinical implications of such practices to ensure safe, effective and coordinated health policy and patient care.

Interaction between phytotherapy and oral anticancer agents: prospective study and literature review

Cancer is becoming more prevalent in elderly patient. Due to polypharmacy, older adults with cancer are predisposed to drug-drug interactions. There is also an increasing interest in the use of complementary and alternative medicine (CAM). Thirty to seventy percent of patients with cancer have used CAM. Through pharmaceutical counseling sessions, we can provide advices on herb-drug interactions (HDI). All the patients seen in pharmaceutical counseling sessions were prospectively included. Information was collected during these sessions: prescribed medication (oral anticancer agents (OAA) and other drugs), CAM (phytotherapy especially), and use of over-the-counter (OTC) drugs. If pharmacist considered an interaction or an intervention clinically relevant, the oncologist was notified. Then, a literature review was realized to identify the potential HDI (no interactions, precautions for use, contraindication). Among 201 pharmacist counseling sessions, it resulted in 104 interventions related to 46 HDI, 28 drug-drug interactions and 30 others (wrong dosage, omission…). To determine HDI, we review 73 medicinal plants which are used by our patients with cancer and 31 OAA. A total of 1829 recommendations were formulated about 59 (75%) medical plants and their interaction with an OAA. Herb-drug interactions should not be ignored by healthcare providers in their management of cancer patients in daily practice.

The mechanisms of pharmacokinetic food-drug interactions - A perspective from the UNGAP group

The simultaneous intake of food and drugs can have a strong impact on drug release, absorption, distribution, metabolism and/or elimination and consequently, on the efficacy and safety of pharmacotherapy. As such, food-drug interactions are one of the main challenges in oral drug administration. Whereas pharmacokinetic (PK) food-drug interactions can have a variety of causes, pharmacodynamic (PD) food-drug interactions occur due to specific pharmacological interactions between a drug and particular drinks or food. In recent years, extensive efforts were made to elucidate the mechanisms that drive pharmacokinetic food-drug interactions. Their occurrence depends mainly on the properties of the drug substance, the formulation and a multitude of physiological factors. Every intake of food or drink changes the physiological conditions in the human gastrointestinal tract. Therefore, a precise understanding of how different foods and drinks affect the processes of drug absorption, distribution, metabolism and/or elimination as well as formulation performance is important in order to be able to predict and avoid such interactions. Furthermore, it must be considered that beverages such as milk, grapefruit juice and alcohol can also lead to specific food-drug interactions. In this regard, the growing use of food supplements and functional food requires urgent attention in oral pharmacotherapy. Recently, a new consortium in Understanding Gastrointestinal Absorption-related Processes (UNGAP) was established through COST, a funding organisation of the European Union supporting translational research across Europe. In this review of the UNGAP Working group "Food-Drug Interface", the different mechanisms that can lead to pharmacokinetic food-drug interactions are discussed and summarised from different expert perspectives.

Complementary medicine use during cancer treatment and potential herb-drug interactions from a cross-sectional study in an academic centre

Complementary medicine (CM) is used by one third to one half of cancer patients throughout the world. The objective of this study was to describe the prevalence of CM use and the potential for interactions with cancer treatments in an academic oncology centre. A cross-sectional study was conducted among patients undergoing current cancer treatment. Among 132 included patients, 56% had used CM since their cancer diagnosis and 45% were using CM during cancer treatment at the time of the survey. The main CM used were green tea (35%), herbal tea (35%), homeopathy (27%), dietary supplements (27%), and herbal medicines (27%). A small majority of patients (58%) spontaneously mentioned the use of CM to their oncologist. Of 42 identified combinations of concomitant use of biologically based CM and anticancer agents among the study patients, the potential for pharmacokinetic interactions of clinical relevance was not expected in 17 combinations (40%), hypothetical and deemed unlikely in 23 (55%), and of probable low clinical relevance in 2 (5%). Considering the high prevalence of CM use, active enquiries should be made by healthcare professionals to detect symptoms that may relate to CM tolerance and effects or that suggest interactions between CM and cancer treatments.

Investigation of antioxidant activity of selenium compounds and their mixtures with tea polyphenols

The antioxidant interactions between selenium species and tea polyphenols were investigated using 1,1-diphenyl-2-picryl-hydrazyl (DPPH) radicals, cupric reducing antioxidant capacity (CUPRAC) and Folin-Ciocalteu (FC) assay. Se(IV) exhibited the lowest antioxidant properties in comparison to other selenium compounds in all assays. The highest reducing power was obtained for SeMet, while the highest ability to scavenging DPPH radicals for MeSeCys. The results obtained experimentally for the mixtures containing selenium species and green or black tea infusion were compared with theoretical values calculated by adding up the effects of both individual components analyzed separately. The results obtained from each assay clearly show that observed effect is not additive. In almost every case the theoretical value of antioxidant capacity was significantly higher from that obtained from the activity of the binary mixture of black tea infusion with selenium compound decreased in the order: SeMet > Se(IV) > Se(VI) > MeSeCys, while for similar mixtures with green tea infusion: MeSeCys > Se(VI) > SeMet ~ Se(IV).

Quercetin and kaempferol increase the intestinal absorption of isorhamnetin coexisting in Elaeagnus rhamnoides (L.) A. Nelson (Elaeagnaceae) extracts via regulating multidrug resistance-associated protein 2

BACKGROUND

Isorhamnetin (IS) is a flavonoid component with many biological activities such as antioxidant, anti-inflammatory, and anticancer, which is also the main active component in total flavones of Elaeagnus rhamnoides (L.) A. Nelson (Elaeagnaceae) (TFH); however, the interaction between IS and other components in TFH is unclear.

PURPOSE

The aim of the present study was to investigate the enhancement of quercetin (QU) or kaempferol (KA) on the intestinal absorption of IS coexisting in TFH, and then preliminarily illuminate the related mechanisms.

METHODS

Firstly, the intestinal absorption of IS in the presence or absence of QU or KA was conducted by in vivo pharmacokinetics model, in situ single-pass intestinal perfusion model (SPIP), and MDCK II-MRP2 monolayer cell model to confirm the enhancement of QU or KA on IS absorption. Secondly, the effects of multidrug resistance-associated protein 2 (MRP2) inhibitors on the IS intestinal absorption were investigated to ascertain the mediation of MRP2 on IS absorption. Finally, the effects of QU or KA on MRP2 activity, protein expression, and mRNA level were performed by SPIP, everted-gut sacs, western blotting, and real-time polymerase chain reaction experiments to elucidate the related mechanisms.

RESULTS

QU or KA increased IS intestinal absorption according to the increased AUC_0-96h, C_max, and P_eff of IS after co-administrated with QU or KA to rats; the oral absorption of IS was mediated by MRP2 based on the facts that the average plasma concentration, AUC_0-96h, and P_eff of IS were increased when co-administrated with PR or MK571 (MRP2 inhibitors) as well as the P_ratio(BL/AP) of IS was decreased by MK571 in MDCK II-MRP2 cell monolayer; the activity, protein expression, and mRNA level of MRP2 were inhibited or down-regulated by QU or KA because of the increased P_eff of MRP2 substrate calcein (CA) and the down-regulated relative protein and mRNA intensity after co-treated with QU or KA.

CONCLUSION

QU and KA increased the intestinal absorption of IS in TFH by regulating the activity and expression of MRP2, which provides useful information for the investigation of the transporter-mediated interaction of flavonoid components in herbal extracts.

Drug Bioavailability Enhancing Agents of Natural Origin (Bioenhancers) that Modulate Drug Membrane Permeation and Pre-Systemic Metabolism

Many new chemical entities are discovered with high therapeutic potential, however, many of these compounds exhibit unfavorable pharmacokinetic properties due to poor solubility and/or poor membrane permeation characteristics. The latter is mainly due to the lipid-like barrier imposed by epithelial mucosal layers, which have to be crossed by drug molecules in order to exert a therapeutic effect. Another barrier is the pre-systemic metabolic degradation of drug molecules, mainly by cytochrome P450 enzymes located in the intestinal enterocytes and liver hepatocytes. Although the nasal, buccal and pulmonary routes of administration avoid the first-pass effect, they are still dependent on absorption of drug molecules across the mucosal surfaces to achieve systemic drug delivery. Bioenhancers (drug absorption enhancers of natural origin) have been identified that can increase the quantity of unchanged drug that appears in the systemic blood circulation by means of modulating membrane permeation and/or pre-systemic metabolism. The aim of this paper is to provide an overview of natural bioenhancers and their main mechanisms of action for the nasal, buccal, pulmonary and oral routes of drug administration. Poorly bioavailable drugs such as large, hydrophilic therapeutics are often administered by injections. Bioenhancers may potentially be used to benefit patients by making systemic delivery of these poorly bioavailable drugs possible via alternative routes of administration (i.e., oral, nasal, buccal or pulmonary routes of administration) and may also reduce dosages of small molecular drugs and thereby reduce treatment costs.

Nutraceuticals' Novel Formulations: The Good, the Bad, the Unknown and Patents Involved

Traditional nutraceuticals and cosmeceuticals hold pragmatic nature with respect to their definitions, claims, purposes and marketing strategies. Their definitions are not well established worldwide. They also have different regulatory definitions and registration regulatory processes in different parts of the world. Global prevalence of nutraceuticals and cosmeceuticals is noticeably high with large market share with minimal regulation compared to traditional drugs. The global market is flooded with nutraceuticals and cosmeceuticals claiming to be of natural origin and sold with a therapeutic claim by major online retail stores such as Amazon and eBay. Apart from the traditional formulations, many manufacturers and researchers use novel formulation technologies in nutraceutical and cosmeceutical formulations for different reasons and objectives. Manufacturers tend to differentiate their products with novel formulations to increase market appeal and sales. On the other hand, researchers use novel strategies to enhance nutraceuticals and cosmeceuticals activity and safety. The objective of this review is to assess the current patents and research adopting novel formulation strategies in nutraceuticals and cosmeceuticals. Patents and research papers investigating nutraceutical and cosmeceutical novel formulations were surveyed for the past 15 years. Various nanosystems and advanced biotechnology systems have been introduced to improve the therapeutic efficacy, safety and market appeal of nutraceuticals and cosmeceuticals, including liposomes, polymeric micelles, quantum dots, nanoparticles, and dendrimers. This review provides an overview of nutraceuticals and cosmeceuticals current technologies, highlighting their pros, cons, misconceptions, regulatory definitions and market. This review also aims in separating the science from fiction in the nutraceuticals and cosmeceuticals development, research and marketing.