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Traccis F, Presciuttini R, Pani PP, Sinclair JMA, Leggio L, Agabio R. Alcohol-medication interactions: A systematic review and meta-analysis of placebo-controlled trials. Neurosci Biobehav Rev 2021; 132:519-541. [PMID: 34826511 DOI: 10.1016/j.neubiorev.2021.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 09/20/2021] [Accepted: 11/15/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Francesco Traccis
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy.
| | - Riccardo Presciuttini
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy.
| | - Pier Paolo Pani
- Health Social Services Public Health Trust Sardinia, Cagliari, Italy.
| | | | - Lorenzo Leggio
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Institute on Drug Abuse Intramural Research Program and National Institute on Alcohol Abuse and Alcoholism, Division of Intramural Clinical and Basic Research, National Institutes of Health, Baltimore and Bethesda, MD, United States; Medication Development Program, National Institute on Drug Abuse Intramural Research Program, National Institutes of Health, Baltimore, United States; Center for Alcohol and Addiction Studies, Brown University, Providence, RI, United States; Division of Addiction Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States; Department of Neuroscience, Georgetown University, Washington, DC, United States.
| | - Roberta Agabio
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy.
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Tanaka E. Toxicological interactions between alcohol and benzodiazepines. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2002; 40:69-75. [PMID: 11990206 DOI: 10.1081/clt-120002887] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND We review recentfindings on the toxicological interactions between alcohol (ethanol) and benzodiazepines, and the combined use of benzodiazepines and alcohol in fatal poisoning. Acute ingestion of alcohol combined with benzodiazepines is responsible for several toxicological interactions that can have significant clinical implications. In general, metabolism of these drugs is delayed when combined with acute alcohol ingestion although some reports suggest otherwise. Alternately, the drugs metabolized during chronic alcohol ingestion have an increased clearance. The net effect may also be influenced by internal (e.g., disease, age) and external (e.g., environment, diet) factors. Fatal poisoning involving coadministration of alcohol and benzodiazepine, especially triazolam, continues to be a serious problem.
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Affiliation(s)
- Einosuke Tanaka
- Department of Legal Medicine, Institute of Community Medicine, University of Tsukuba, Ibaraki-ken, Japan.
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Frackiewicz EJ, Sramek JJ, Cutler NR. Gender differences in depression and antidepressant pharmacokinetics and adverse events. Ann Pharmacother 2000; 34:80-8. [PMID: 10669189 DOI: 10.1345/aph.18465] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review data generated by studies examining gender differences in the prevalence of depression, as well as in antidepressant pharmacokinetics, pharmacodynamics, and adverse events. DATA SOURCES Published articles and abstracts were identified through MEDLINE (January 1966-April 1999) using the following search terms: antidepressant, response, gender, pharmacokinetic, pharmacodynamic, female, side effect, and adverse events. All articles that assessed gender differences in antidepressant response, pharmacokinetics, and adverse events, as well as articles that evaluated postulated mechanisms for these differences, were reviewed. Additional articles were identified from bibliographies of retrieved articles. STUDY SELECTION AND DATA EXTRACTION All relevant abstracts, studies, and review articles were evaluated. DATA SYNTHESIS Gender differences in the prevalence of depression have been reported and may result from the interaction of several factors. Women have been shown to have a higher incidence of depression, which may be due to artifact, social, or biologic reasons. Studies suggest that the pharmacokinetic disposition of popular antidepressants varies between men and women, and women taking antidepressants may exhibit a different adverse event profile. Only one study specifically evaluated gender differences in antidepressant treatment response. CONCLUSIONS Further research elucidating gender differences in response to antidepressant treatment and on depression prevalence is needed. Some studies report that the pharmacokinetics of antidepressants may vary between men and women. Therefore, clinicians should be aware that potential differences in antidepressant pharmacokinetics may exist, and a dosage adjustment may be necessary for women to ensure a favorable drug response, compliance, and decreased incidence of adverse events.
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Abstract
The reports of interactions between benzodiazepines (BZPs) and other drugs (e.g., antidepressants, selective serotonin reuptake inhibitors, antiulcer drugs, antiepileptic drugs, macrolide antibiotics) during their combined use are reviewed. In general, metabolism of BZPs is delayed when combined with a number of other drugs but some reports have suggested otherwise. In recent years, the cytochrome P450 (P450 or CYP) isoenzyme that catalyses the metabolism of BZPs has also been identified. BZPs are mainly catalysed by CYP3A4. When published reports are studied, it appears necessary to be exceptionally careful about interactions mainly between BZPs and selective serotonin reuptake inhibitors, cimetidine, antiepileptic drugs, macrolide antibiotics and antimycotics. More information is necessary to identify individuals at greatest risk of drug interactions and adverse events.
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Affiliation(s)
- E Tanaka
- Institute of Community Medicine, University of Tsukuba, Japan
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Tanaka E, Misawa S. Pharmacokinetic interactions between acute alcohol ingestion and single doses of benzodiazepines, and tricyclic and tetracyclic antidepressants -- an update. J Clin Pharm Ther 1998; 23:331-6. [PMID: 9875680 DOI: 10.1046/j.1365-2710.1998.00175.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Recent reports of interactions between alcohol and benzodiazepines, tricyclic and tetracyclic antidepressants during their acute concomitant use are reviewed. Acute ingestion of alcohol (ethanol) with tranquilizers or hypnotics is responsible for several pharmacokinetic interactions that can have significant clinical implications. In general, metabolism of these drugs is delayed when combined with alcohol but some reports have suggested otherwise. The amount of alcohol consumed, the presence or absence of liver disease, and differences in the dosage and administration of these drugs may account for the observed discrepancies. In recent years, the cytochrome P450 (P450 or CYP) isoenzyme that catalyses the metabolism of these drugs has also been identified. However, since changes in the pharmacogenetic metabolism of benzodiazepines and tricyclic and tetracyclic antidepressants are mainly governed by CYP2C19 and CYP2D6, caution is needed when used together with alcohol.
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Affiliation(s)
- E Tanaka
- Institute of Community Medicine, University of Tsukuba, Japan.
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Frackiewicz EJ, Sramek JJ, Herrera JM, Kurtz NM, Cutler NR. Ethnicity and antipsychotic response. Ann Pharmacother 1997; 31:1360-9. [PMID: 9391692 DOI: 10.1177/106002809703101114] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To review the data generated by studies examining interethnic/racial differences in response to antipsychotics. DATA SOURCES A MEDLINE search (1966-1996) identified all articles examining differences in antipsychotic response among Caucasians, Asians, Hispanics, and African-Americans, as well as articles evaluating postulated mechanisms for these differences. STUDY SELECTION All abstracts, studies, and review articles were evaluated. DATA SYNTHESIS Ethnic/racial differences in response to antipsychotic medications have been reported and may be due to genetics, kinetic variations, dietary or environmental factors, or variations in the prescribing practices of clinicians. Studies suggest that Asians may respond to lower doses of antipsychotics due to pharmacokinetic and pharmacodynamic differences. Research relevant to African-Americans is limited, but some studies suggest that differences in this group may be due to clinician biases and prescribing practices, rather than to pharmacokinetic or pharmacodynamic variability. CONCLUSIONS Future research directed at validating the hypotheses that different ethnic/racial groups show variations in response to antipsychotics should focus on homogeneous ethnic groups, use recent advances in pharmacogenetic testing, and control for such variables as observer bias, gender, disease chronicity, dietary and environmental factors, and exposure to enzyme-inducing and -inhibiting agents. Clinicians should be aware that potential interethnic/racial differences in pharmacodynamics and pharmacokinetics may exist that can alter response to antipsychotics.
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Jacobsen D, Sebastian CS, Dies DF, Breau RL, Spann EG, Barron SK, McMartin KE. Kinetic interactions between 4-methylpyrazole and ethanol in healthy humans. Alcohol Clin Exp Res 1996; 20:804-9. [PMID: 8865952 DOI: 10.1111/j.1530-0277.1996.tb05255.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
4-Methylpyrazole (4-MP), a potent inhibitor of alcohol dehydrogenase activity, is a candidate to replace ethanol as the antidote for methanol and ethylene glycol intoxications, because it has a longer duration of action and apparently fewer adverse effects. To study a probable mutual inhibitory effect between ethanol and 4-MP on their elimination, two studies were performed in healthy human volunteers using double-blind crossover designs. In study A1 4-MP in the presumed therapeutic dose range of 10 to 20 mg/kg caused a 40% reduction in the rate of elimination of ethanol in 12 subjects given 0.5 to 0.7 g/kg of ethanol. These data suggest that such doses of 4-MP inhibit alcohol dehydrogenase activity in humans in vivo and would be effective at blocking methanol or ethylene glycol metabolism. In study B, ethanol (0.6 g/kg followed by 0.2 g/kg twice) significantly decreased the rate of elimination of 4-MP (5 mg/kg, given intravenously to four subjects). These moderate doses of ethanol also inhibited the rate of urinary excretion of 4-carboxypyrazole, the primary metabolite of 4-MP in humans. Data suggest that ethanol inhibits 4-MP metabolism, thereby increasing the duration of therapeutic blood levels of 4-MP in the body. This mutual interaction may have clinical implications, because most self-poisoned patients have also ingested ethanol. Theoretically, methanol and ethylene glycol might also show such interactions with 4-MP.
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Affiliation(s)
- D Jacobsen
- Department of Pharmacology, Louisiana State University Medical Center, Shreveport 71130-3932, USA
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Muhoberac BB, Hanew T, Halter S, Schenker S. A model of cytochrome P-450-centered hepatic dysfunction in drug metabolism induced by cobalt-protoporphyrin administration. Biochem Pharmacol 1989; 38:4103-13. [PMID: 2512932 DOI: 10.1016/0006-2952(89)90692-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Cobalt-protoporphyrin treatment disrupts cytochrome P-450-centered drug metabolism and is known to decrease significantly the cytochrome P-450 content of the liver. This study assesses further the correlations between biochemical and functional changes induced by Co-protoporphyrin. Specifically, it confirmed the fall in cytochrome P-450 levels in liver and demonstrated that both NADPH-cytochrome P-450 reductase and NADH-cytochrome b5 reductase activities decreased in a dose-dependent manner, albeit to a lesser degree, upon Co-protoporphyrin administration. Furthermore, plasma clearance of the marker drug aminopyrine fell off abruptly with a minimal decrease in cytochrome P-450 content, and then monotonically with its further depletion. Both aminopyrine and caffeine demethylation, as measured by the amount of radiolabeled CO2 exhaled, also decreased with diminishing cytochrome P-450 content. With aminopyrine the decrease was abrupt but with caffeine biphasic, consistent with preferential isozyme depletion. The drop in oxidative drug metabolism measured by these two in vivo techniques occurred in the absence of organellar damage to hepatocytes, as observed by electron microscopy. In vitro studies of aminopyrine metabolism in microsomes prepared from rats with and without Co-protoporphyrin injection proved to be consistent with the in vivo studies. Moreover aminopyrine Vmax decreased and Km increased with decreasing cytochrome P-450 content, suggesting preferential isozyme depletion. Furthermore, the changes in aminopyrine intrinsic clearance predicted by the in vitro Vmax and Km values agreed with those measured by in vivo plasma clearance. Taken together, these data suggest that Co-protoporphyrin treatment can be used to produce a model of altered cytochrome P-450-centered drug metabolism, as measured consistently by several techniques. However, this model appears to be more complex than one involving nonspecific depletion of cytochrome P-450 alone, and may be influenced also by concomitant changes in the electron transport chain or other aspects of hepatic metabolism.
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Affiliation(s)
- B B Muhoberac
- Department of Chemistry, Purdue University School of Science, Indiana University-Purdue University, Indianapolis 46205
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Masur J, Souza-Formigoni ML, Pires ML. Increased stimulatory effect by the combined administration of cocaine and alcohol in mice. Alcohol 1989; 6:181-2. [PMID: 2736076 DOI: 10.1016/0741-8329(89)90015-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Locomotor activity was recorded after 5-30 mg/kg of cocaine in mice pretreated or not with a stimulant dose of ethanol (2.0 g/kg). The increase in locomotion induced by the association of cocaine plus ethanol was significantly larger when compared to either the group injected with only cocaine or only ethanol.
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Affiliation(s)
- J Masur
- Department of Psicobiologia, Escola Paulista de Medicina, São Paulo, Brazil
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Affiliation(s)
- R B Scott
- Department of Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298
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McMartin KE, Collins TD. Distribution of oral 4-methylpyrazole in the rat: inhibition of elimination by ethanol. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1988; 26:451-66. [PMID: 3230597 DOI: 10.3109/15563658809038561] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
4-Methylpyrazole (4-MP), a potent competitive inhibitor of alcohol dehydrogenase activity, is being studied as a therapeutic agent for methanol and ethylene glycol poisoning. In order to evaluate the distribution of 4-MP using doses in the potentially therapeutic range, male Sprague-Dawley rats were administered 4-MP orally at zero time in doses of 5, 10, or 20 mg/kg. Half of the rats were also treated orally at 0, 1, 2, and 3 h with ethanol (1 g/kg each h) and half with glucose in isocaloric amounts. At doses of 10 and 20 mg/kg, 4-MP elimination appeared to be saturated, with an elimination rate of 10 mumol/L/h. Elimination at 5 mg/kg was non-conclusive as to the order. The rate of 4-MP elimination was decreased about 50% by concomitant administration of ethanol. Urinary excretion of unchanged 4-MP accounted for only about 1% of the dose; the amount excreted unchanged was significantly increased by ethanol administration. The results demonstrate the mutual inhibition of metabolism by ethanol and 4-methylpyrazole, which may explain why the inhibition of ADH by 4-MP can be longer than that predicted by the elimination rate of 4-MP alone.
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Affiliation(s)
- K E McMartin
- Department of Pharmacology, Louisiana State University Medical Center, Shreveport 71130-3932
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Teschke R, Gellert J. Hepatic microsomal ethanol-oxidizing system (MEOS): metabolic aspects and clinical implications. Alcohol Clin Exp Res 1986; 10:20S-32S. [PMID: 3544926 DOI: 10.1111/j.1530-0277.1986.tb05176.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Henderson GI, Schenker S. Effects of age, sex, and cimetidine on acute ethanol-induced inhibition of the hepatic monooxygenase systems. Alcohol Clin Exp Res 1986; 10:259-65. [PMID: 3526947 DOI: 10.1111/j.1530-0277.1986.tb05086.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Our aim was to investigate the possible interaction of acute ethanol (E) with the metabolism of other drugs by microsomes isolated from immature and mature rat livers and placenta. The effects of acute in vitro E exposure on the N-demethylation of [14C]aminopyrine and [1-14C]methylcaffeine by these tissues were determined. In addition, the effects of ethanol on these two enzyme systems from male and female livers were compared along with an analysis of ethanol and cimetidine inhibitory interactions. The degree (percentage) of inhibition by acute E (1-3 mg/ml) varied with both age and sex. Aminopyrine demethylase activity was inhibited by E to a greater degree (p less than 0.05) in the adult female than the male. However, when inhibition was expressed in absolute terms (control minus inhibited activity), these inhibitory values varied in direct proportion to initial (control) enzyme activity. Thus, E reduced aminopyrine demethylase from adult male microsomes by 4 times that in the female and in excess of 1000 times the absolute inhibition observed in fetal liver regardless of E concentration. A similar pattern of sex and age differences in caffeine demethylase response to E was observed except that absolute differences in inhibition were less due to smaller variation in control values. In addition, placental caffeine demethylase was highly sensitive to E inhibition (51% at 3 mg/nl) but not to the extent of caffeine demethylase from fetal liver (75% at 3 mg/nl). Finally, it was demonstrated that E interacts with cimetidine in a manner that may be additive.
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Abstract
The cancers consistently associated with ingestion of alcohol, the head and neck cancers, are also associated with tobacco use and arise from epithelia that are in direct contact with both agents. Tobacco smoking-related cancers at sites not directly in contact with alcoholic beverages, that is, lung, bladder, and perhaps pancreas, do not consistently show a relationship to alcohol consumption, although lung and pancreatic tumors are associated in some studies. Liver cancer was thought to be strongly related to alcohol consumption on epidemiological grounds and because of its relationship to cirrhosis. As knowledge of the viral etiology of some cirrhoses has evolved and as methods to detect viruses have developed, the significant association between hepatitis B virus and hepatocellular carcinoma has become clear. Alcohol and hepatitis B virus may interact in the etiology of the disease and have important separate roles as well. There are epidemiologic and experimental data showing that malnutrition (resulting from poor food choice), economic deprivation, or alcoholism contributes to the risk for head, neck, and liver cancers. Colon cancers occur about equally in men and women, are found in well-nourished populations, and are not associated with tobacco smoking. Rectal cancers show a preponderance of cases in men but are frequently found in women as well and are not thought to be associated with smoking or malnutrition. The association between colorectal cancers and alcohol consumption, when it is found, apparently occurs at even relatively low alcohol intakes and is often stronger for consumption of beer than of other beverages. Nutritional and metabolic mechanisms proposed for the influence of alcohol on carcinogenesis are supported by studies in human subjects and laboratory animals. Animal models are needed in which effects of ethanol on carcinogenesis can be consistently demonstrated and which can then be used to examine mechanisms.
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