Food-drug interaction of tacrolimus with pomelo, ginger, and turmeric juice in rats

Prevention and rehabilitation after heart transplantation: A clinical consensus statement of the European Association of Preventive Cardiology, Heart Failure Association of the ESC, and the European Cardio Thoracic Transplant Association, a section of ESOT

Little is known either about either physical activity patterns, or other lifestyle-related prevention measures in heart transplantation (HTx) recipients. The history of HTx started more than 50 years ago but there are still no guidelines or position papers highlighting the features of prevention and rehabilitation after HTx. The aims of this scientific statement are (i) to explain the importance of prevention and rehabilitation after HTx, and (ii) to promote the factors (modifiable/non-modifiable) that should be addressed after HTx to improve patients' physical capacity, quality of life and survival. All HTx team members have their role to play in the care of these patients and multidisciplinary prevention and rehabilitation programmes designed for transplant recipients. HTx recipients are clearly not healthy disease-free subjects yet they also significantly differ from heart failure patients or those who are supported with mechanical circulatory support. Therefore, prevention and rehabilitation after HTx both need to be specifically tailored to this patient population and be multidisciplinary in nature. Prevention and rehabilitation programmes should be initiated early after HTx and continued during the entire post-transplant journey. This clinical consensus.

Prevention and Rehabilitation After Heart Transplantation: A Clinical Consensus Statement of the European Association of Preventive Cardiology, Heart Failure Association of the ESC, and the European Cardio Thoracic Transplant Association, a Section of ESOT

Little is known either about either physical activity patterns, or other lifestyle-related prevention measures in heart transplantation (HTx) recipients. The history of HTx started more than 50 years ago but there are still no guidelines or position papers highlighting the features of prevention and rehabilitation after HTx. The aims of this scientific statement are (i) to explain the importance of prevention and rehabilitation after HTx, and (ii) to promote the factors (modifiable/non-modifiable) that should be addressed after HTx to improve patients' physical capacity, quality of life and survival. All HTx team members have their role to play in the care of these patients and multidisciplinary prevention and rehabilitation programmes designed for transplant recipients. HTx recipients are clearly not healthy disease-free subjects yet they also significantly differ from heart failure patients or those who are supported with mechanical circulatory support. Therefore, prevention and rehabilitation after HTx both need to be specifically tailored to this patient population and be multidisciplinary in nature. Prevention and rehabilitation programmes should be initiated early after HTx and continued during the entire post-transplant journey. This clinical consensus statement focuses on the importance and the characteristics of prevention and rehabilitation designed for HTx recipients.

Evidence of the interactions between immunosuppressive drugs used in autoimmune rheumatic diseases and Chinese herbal medicine: A scoping review

OBJECTIVES

Chinese herbal medicine (CHM) has been shown to be effective in autoimmune rheumatic diseases, but harmful herb-drug interactions might be inherent. We aim to review the evidence regarding herb-drug interactions between immunosuppressive drugs used in autoimmune rheumatic diseases and CHM.

METHODS

We searched PubMed, EMBASE and CINAHL from inception till 30 April 2023 using keywords that encompassed 'herb-drug interactions', 'herbs' and 'immunosuppressants'. Articles were included if they contained reports about interactions between immunosuppressive drugs used in the treatment of rheumatic diseases with CHM. Level of evidence for each pair of interaction was graded using the algorithm developed by Colalto.

RESULTS

A total of 65 articles and 44 unique pairs of interactions were identified. HDIs were reported for cyclophosphamide, cyclosporine, tacrolimus, methotrexate, mycophenolic acid, glucocorticoids, sulfasalazine, tofacitinib and biologic disease-modifying antirheumatic drugs. Among these, cyclosporine (n = 27, 41.5%) and tacrolimus (n = 19, 29.2%) had the highest number of documented interactions. Hypericum perforatum had the highest level of evidence of interaction with cyclosporine and tacrolimus. Consumption reduced the bioavailability and therapeutic effects of the drugs. Schisandra sphenanthera had the highest level of evidence of interaction with tacrolimus and increased the bioavailability of the drug. Majority of the articles were animal studies.

CONCLUSION

Overall level of evidence for the included studies were low, though interactions between cyclosporine, tacrolimus, Hypericum perforatum and Schisandra sphenanthera were the most and well-documented. Healthcare professionals should actively enquire about the concurrent use of CHM in patients, especially when drugs with a narrow therapeutic index are consumed.

Effects of curcumin/turmeric supplementation on the liver enzymes, lipid profiles, glycemic index, and anthropometric indices in non-alcoholic fatty liver patients: An umbrella meta-analysis

Non-alcoholic fatty liver disease (NAFLD) is one of the leading causes of chronic liver disease worldwide. The evidence for curcumin's effects on patients with NAFLD is accumulating; however, meta-analyses have reported mixed results. The current umbrella meta-analysis aimed to assess the present evidence and provide an accurate estimate of the overall effects of curcumin/turmeric on NAFLD patients. The Web of Science, Scopus, PubMed, ScienceDirect, and Google Scholar databases were searched till March 2023 using MeSH terms and related keywords based on the PICO criteria. Meta-analysis studies evaluating the effects of curcumin/turmeric supplementation on NAFLD patients that reported the effect sizes (ES) and corresponding confidence intervals (CI) were eligible for inclusion in this study. All articles were screened by considering the eligibility criteria by two independent reviewers and required data were extracted from the included meta-analyses. The meta-analysis was performed utilizing a random-effects model by STATA software. Findings of 11 meta-analyses of 99 randomized controlled trials comprising 5546 participants revealed that curcumin/turmeric supplementation reduced AST (ES = -1.072, 95% CI (-1.656, -0.488), p = 0.000), ALT (ES = -0.625, 95% CI (-1.170, -0.134), p = 0.014), and TG (ES = -0.469, 95% CI (-1.057, 0.119), p = 0.128) levels, and HOMA-IR (ES = -0.291, 95% CI (-0.368, -0.214), p = 0.000), BMI (ES = -0.205, 95% CI (-0.304, -0.107), p = 0.000), and WC (ES = -1.290, 95% CI (-2.038, -0.541), p = 0.001) in comparison to the control group. However, the effects of curcumin on GGT, ALP, TC, LDL-C, HDL-C, FBS, and HbA1C levels and body weight were not significant. The findings suggest the beneficial effects of curcumin/turmeric supplementation in patients with NAFLD, such as improving liver function, decreasing serum TG levels, ameliorating insulin resistance, and reducing general and central obesity. Nevertheless, high-quality research is further required to prove these achievements.

Spice-drug interactions: a case report on the use of turmeric, curry and ginger in a renal transplant patient on tacrolimus

Tacrolimus is a widely used immunosuppressant for the prevention of rejection after transplantation. In vitro studies suggest that interactions exist between spices and tacrolimus. We present the case of a renal transplant patient aged around 70 years who was treated with prednisone, mycophenolate-mofetil and tacrolimus. The patient had a pre-transplant dietary habit of consuming foods spiced with turmeric, curry and ginger. The following protocol was implemented in parallel with close monitoring of plasma tacrolimus concentrations: administration of 10 g/day of turmeric for 4 days, then 10 g/day of curry for 4 days and then 10 g/day of ginger for 4 days. No change in tacrolimus plasma concentrations during and after the implementation of the protocol was observed. The impact of turmeric, curry and ginger on plasma tacrolimus concentrations seems negligible in vivo although further studies are needed. A shared decision to test the impact of spice consumption in a patient with dietary habits involving these spices seems reasonable.

Signal Detection and Assessment of Herb-Drug Interactions: Saudi Food and Drug Authority Experience

INTRODUCTION

Numerous investigations on herbal medicine that have been undertaken in the past several years demonstrate the general acceptance of its safety. The Saudi Food and Drug Authority (SFDA) established the Herb-Drug Interaction (HDI) project to detect and assess potential HDIs to ensure safety. The aim is to detect safety signals and assess them based on available evidence.

METHODS

First, SFDA-registered herbal products (n = 30) were selected and prioritized based on commonly used herbs. Second, reported potential HDIs were retrieved from the World Health Organization global database of individual case safety reports (VigiBase), AdisInsight®, and the Natural Medicines database. We excluded drugs non-registered by SFDA and labeled interactions in the product information of SFDA, the US Food and Drug Administration (FDA), and the European Medicines Agency (EMA). Finally, a comprehensive evaluation of potential HDIs was carried out using several evidence sources: literature, global cases, local cases, and other relevant documents. The Drug Interaction Probability Scale (DIPS) scale was used to assess the probability of a causal relationship between the interacting herb and drug and the event.

RESULTS

The search yielded 566 potential signals, and 41 had published evidence and were referred for assessment. The assessment results using DIPS were: 22 possible (53.6 %), 7 probable (17%), and 12 doubtful (29.2%) interactions. The recommendation was to include probable HDIs in the product information, including turmeric-tacrolimus, etoposide-Echinacea, Ginkgo biloba-ibuprofen, green tea-warfarin, and licorice-thiazides interactions.

CONCLUSION

The HDI project assessed the screening and identification of potential HDIs. The action plan of this project can be used in post-marketing activities to identify potential drug interactions.

From Listing to Recovery: A Review of Nutritional Status Assessment and Management in Liver Transplant Patients

Liver transplantation (LT) is a complex surgical procedure requiring thorough pre- and post-operative planning and care. The nutritional status of the patient before, during, and after LT is crucial to surgical success and long-term prognosis. This review aims to assess nutritional status assessment and management before, during, and after LT, with a focus on patients who have undergone bariatric surgery. We performed a comprehensive topic search on MEDLINE, Ovid, In-Process, Cochrane Library, EMBASE, and PubMed up to March 2023. It identifies key factors influencing the nutritional status of liver transplant patients, such as pre-existing malnutrition, the type and severity of liver disease, comorbidities, and immunosuppressive medications. The review highlights the importance of pre-operative nutritional assessment and intervention, close nutritional status monitoring, individualised nutrition care plans, and ongoing nutritional support and monitoring after LT. The review concludes by examining the effect of bariatric surgery on the nutritional status of liver transplant recipients. The review offers valuable insights into the challenges and opportunities for optimising nutritional status before, during, and after LT.

The effect of curcumin on anthropometric indices, blood pressure, lipid profiles, fasting blood glucose, liver enzymes, fibrosis, and steatosis in non-alcoholic fatty livers

Background

Non-alcoholic fatty liver disease (NAFLD) is the most common form of liver disease. Curcumin is a natural polyphenol that may be effective against liver steatosis and steatohepatitis. The present study aimed to evaluate the effects of phytosomal curcumin on lipid profile, fasting blood sugar, anthropometric indices, liver enzymes, fibrosis, and steatosis in non-alcoholic fatty liver patients.

Methods

The participants were randomized to the curcumin-phosphatidylserine phytosomal receiving group and the placebo receiving group and were followed up for 12 weeks. Data on anthropometric indices, lipid profile, blood glucose, blood pressure, liver enzymes, hepatic steatosis, and fibrosis were collected at the beginning and the end of the clinical trial.

Results

Supplementation for 12 weeks with phytosomal curcumin significantly reduced fibrosis and steatosis in the phytosomal curcumin receiving group compared with the placebo group (p < 0.05). Phytosomal curcumin also significantly reduced waist circumference and blood pressure compared with the placebo group (p < 0.05). There was no significant difference between the phytosomal curcumin and the placebo groups regarding changes in weight, body mass index, fasting blood glucose, liver enzymes, and lipid profile.

Conclusion

Curcumin, at a dose of 250 mg per day, might be effective in treating patients with NAFLD. Further studies are necessary to confirm these findings and to discover the underlying mechanisms.

Clinical trial registration

https://www.irct.ir/trial/43730, identifier: IRCT20121216011763N39.

Potential profound fluctuation in tacrolimus concentration on consumption of pomegranate rind extract: A Pharmacokinetic Experiment

Background: Presently, varied case reports demonstrated an increase or decrease in blood concentration of diverse conventional drugs, often co-administered with edible fruits, spices, or vegetables. The overarching aim of this research is to elucidate the fluctuations in tacrolimus (TAC) blood concentration on the consumption of pomegranate rind extract (PRE). Methods: A pharmacokinetic (PK) study was conducted with two groups, vis-a-vis PRE + TAC (3 mg/kg) and TAC (3 mg/kg) alone groups. An experimental study was conducted in three different manners: Single-dose (S) PRE (200 mg/kg), 7-day repetitive (7-R) PRE (200 mg/kg) dosing, and multiple (M) PRE doses (100, 200, 400, and 800 mg/kg). All the blood samples (approximately 300 μl) were drawn at different time intervals, i.e., 30 min, 1, 2, 4, 8, and 12 h after oral administration of TAC (3 mg/kg). The estimation of TAC in rat plasma was done using the hyphenated technique LC-MS/MS where the mass spectrometer used was a triple-stage quadrupole in multiple-reaction monitoring (MRM) mode. Results: The findings depict that in comparison with the TAC (3 mg/kg) alone group with the 7-day repetitive (7-R) PRE (200 mg/kg) dosing, the Cmax was found to be 9.03 ± 1.21 ng/ml; AUC from time zero to infinity (AUC0-∞), 61.91 ± 17.37 ngh/ml, while the TAC (3 mg/kg) + PRE group exhibited an increase in PK parameters of TAC (Cmax 22.48 ± 3.07 ng/ml; AUC0-∞ 153.08 ± 13.24 ng h/ml). The authors further investigated in what manner the PRE affects the PK of TAC in animals. For this, docking studies with major phytoconstituents present in the PRE with CYP3A4 isoenzyme were carried out. Ellagitannins (dock score, -11.64) and punicalagin (dock score, -10.68) were again used for molecular simulation studies with TAC. To validate our findings, a CYP3A4 inhibitory in vitro assay was conducted. Conclusion: Based on the integrated in vivo and in silico studies, we concluded that pomegranate rind extract interacts strongly with CYP isoenzyme and is therefore responsible for the altered PK profile of TAC.

Nutrition Disturbances and Metabolic Complications in Kidney Transplant Recipients: Etiology, Methods of Assessment and Prevention-A Review

Nutrition disturbances occur at all stages of chronic kidney disease and progress with the decrease of the kidney filtration rate. Kidney transplantation (KTx) as the best form of kidney replacement therapy poses various nutritional challenges. Prior to transplantation, recipients often present with mild to advanced nutrition disturbances. A functioning allograft not only relieves uremia, acidosis, and electrolyte disturbances, but also resumes other kidney functions such as erythropoietin production and vitamin D3 metabolism. KTx recipients represent a whole spectrum of undernutrition and obesity. Since following transplantation, patients are relieved of most dietary restrictions and appetite disturbances; they resume old nutrition habits that result in weight gain. The immunosuppressive regimen often predisposes them to dyslipidemia, glucose intolerance, and hypertension. Moreover, most recipients present with chronic kidney graft disease at long-term follow-ups, usually in stages G2-G3T. Therefore, the nutritional status of KTx patients requires careful monitoring. Appropriate dietary and lifestyle habits prevent nutrition disturbances and may improve kidney graft function. Despite many nutritional guidelines and recommendations targeted at chronic kidney disease, there are few targeted at KTx recipients. We aimed to provide a brief review of nutrition disturbances and known nutritional recommendations for kidney transplant recipients based on the current literature and dietary trends.

Controversial Interactions of Tacrolimus with Dietary Supplements, Herbs and Food

Tacrolimus is an immunosuppressive calcineurin inhibitor used to prevent rejection in allogeneic organ transplant recipients, such as kidney, liver, heart or lung. It is metabolized in the liver, involving the cytochrome P450 (CYP3A4) isoform CYP3A4, and is characterized by a narrow therapeutic window, dose-dependent toxicity and high inter-individual and intra-individual variability. In view of the abovementioned facts, the aim of the study is to present selected interactions between tacrolimus and the commonly used dietary supplements, herbs and food. The review was based on the available scientific literature found in the PubMed, Scopus and Cochrane databases. An increase in the serum concentration of tacrolimus can be caused by CYP3A4 inhibitors, such as grapefruit, pomelo, clementine, pomegranate, ginger and turmeric, revealing the side effects of this drug, particularly nephrotoxicity. In contrast, CYP3A4 inducers, such as St. John’s Wort, may result in a lack of therapeutic effect by reducing the drug concentration. Additionally, the use of Panax ginseng, green tea, Schisandra sphenanthera and melatonin in patients receiving tacrolimus is highly controversial. Therefore, since alternative medicine constitutes an attractive treatment option for patients, modern healthcare should emphasize the potential interactions between herbal medicines and synthetic drugs. In fact, each drug or herbal supplement should be reported by the patient to the physician (concordance) if it is taken in the course of immunosuppressive therapy, since it may affect the pharmacokinetic and pharmacodynamic parameters of other preparations.

The effects of curcumin supplementation on metabolic biomarkers and body mass index in patients with nonalcoholic fatty liver disease, a systematic review and meta-analysis of randomized controlled trials

Background and Aims:

Curcumin is one of the most commonly used indigenous molecules endowed with various shielding functionalities that protect the liver. In the present research, we aimed to investigate the effects of curcumin on metabolic factors and body mass index (BMI) in patients with non-alcoholic fatty liver disease (NAFLD), using a meta-analysis of randomized, controlled trials.

Methods::

Online databases PubMed, Embase, Web of Science, and Science Direct were searched until April 2021 to identify eligible articles. Fourteen trials were included. Results: The results showed that curcumin consumption could significantly reduce AST (-0.35, (-0.57 to -0.14)), total cholesterol (-0.81, (-1.34 to -0.27)), TG (-0.49, (-0.71 to -0.27)), and FBS (-0.28, (-0.46 to -0.09)) in patients with NAFLD. However, the improvements in ALT (-0.29, (-0.58 to 0.00)), LDL (-0.48, (-0.97 to 0.01)), HDL (0.03, (-0.38 to 0.44)), and BMI (-0.13, (-0.29 to 0.02)) were not statistically significant. Furthermore, the findings revealed that the optimal dose and duration of curcumin consumption for patients with NAFLD is <500 mg/d for less than 10 weeks.

Conclusions:

The present study suggests that consuming curcumin can improve liver enzymes, lipid profile, FBS, and BMI in patients with NAFLD. Moreover, curcumin supplementation may provide beneficial effects on metabolic biomarkers and body weight if used at the appropriate dose and duration. Further RCTs are required to confirm our findings.

Herb-Drug Interaction in Inflammatory Diseases: Review of Phytomedicine and Herbal Supplements

Many people worldwide use plant preparations for medicinal purposes. Even in industrialized regions, such as Europe, where conventional therapies are accessible for the majority of patients, there is a growing interest in and usage of phytomedicine. Plant preparations are not only used as alternative treatment, but also combined with conventional drugs. These combinations deserve careful contemplation, as the complex mixtures of bioactive substances in plants show a potential for interactions. Induction of CYP enzymes and pGP by St John's wort may be the most famous example, but there is much more to consider. In this review, we shed light on what is known about the interactions between botanicals and drugs, in order to make practitioners aware of potential drug-related problems. The main focus of the article is the treatment of inflammatory diseases, accompanied by plant preparations used in Europe. Several of the drugs we discuss here, as basal medication in chronic inflammatory diseases (e.g., methotrexate, janus kinase inhibitors), are also used as oral tumor therapeutics.

Effects of curcumin supplementation on vitamin D levels in women with premenstrual syndrome and dysmenorrhea: a randomized controlled study

Background

Vitamin D has an established role in female reproduction. There is also evidence for an association between vitamin D levels and menstrual problems such as premenstrual syndrome (PMS) and dysmenorrhea. Curcumin, is a bioactive polyphenol constituent of turmeric, that can potentially interact with vitamin D receptors and its molecular targets. This study evaluated the effects of curcumin on vitamin D levels in young women with PMS and dysmenorrhea.

Methods

In this randomized, triple-blind, placebo-controlled trial, women with PMS and dysmenorrhea were divided randomly into experimental and control groups to receive one capsule (500 mg of curcuminoid+ 5 mg piperine, or placebo) daily, from approximately 7 days before until 3 days after menstruation for three consecutive menstrual cycles. Serum vitamin D levels, renal function, and liver enzymes were also measured before and after intervention.

Results

A total of 76 subjects (38 in each group) were recruited into the trial. Curcumin significantly increased the median (IQR) serum levels of vitamin D [from 12.8 ng/ml (7.0–24.6) to 16.2 ng/ml (6.4–28.8); P = 0.045], compared with placebo [from 18.6 ng/ml (2.2–26.8) to 21.3 ng/ml (5.2–27.1); P = 0.17]. Serum levels of aspartate aminotransferase and direct bilirubin were reduced by the end of trial in the curcumin group (p < 0.05), but did not change significantly in the control group (p > 0.05). Finally, no significant differences in levels of fasting blood glucose were detected between curcumin and placebo groups.

Conclusion

Curcumin supplementation in women with PMS and dysmenorrhea led to a significant improvement of vitamin D, liver function enzyme test, but did not affect blood glucose.

Trial registration

The trial was registered on Iranian Registry of Clinical Trials registry (Trial ID: IRCT20191112045424N1 on 23 January 2020; available at https://www.irct.ir).

Steatosis induced by nonylphenol in HepG2 cells and the intervention effect of curcumin

Non-alcoholic fatty liver disease (NAFLD) has increasingly become a serious public health problem. There is growing evidence that nonylphenol (NP) exposure may cause steatosis, but the underlying mechanism is not fully understood. Curcumin (CUR) improves NAFLD-related lipid metabolism disorders and oxidative stress, but its preventive and therapeutic effects on NP-induced steatosis have not been reported. The objective of this investigation was to determine the capability and potential mechanism of NP to induce steatosis in vitro and the intervention of curcumin. HepG2 cells were treated with 0 μM, 20 μM, 30 μM, 40 μM NP for 24 h. Lipid droplets accumulated significantly in HepG2 cells after NP treatment, and the concentration of triglyceride (TG) and total cholesterol (T-CHO) increased significantly. Simultaneously, lipogenesis gene expression was up-regulated significantly, fatty acid oxidation (FAO) gene expression was significantly down-regulated, and reactive oxygen species (ROS) were overproduced. Meanwhile, the expression of p-AMPK/AMPK in the AMPK/mTOR signaling pathway was significantly down-regulated and the expression of p-mTOR/mTOR was markedly up-regulated. However, blocking ROS production with N-acetyl-L-cysteine (NAC) can reverse these phenomena. In addition, our study found that curcumin effectively ameliorated the effects of NP-induced steatosis. Our study indicates that NP can induce steatosis in HepG2 cells, and may be implicated in inhibiting the ROS-dependent AMPK/mTOR pathway, and that curcumin ameliorates the NAFLD-like changes induced by NP in HepG2 cells.

The Effect of Single-Dose Ougan Juice Application on the Pharmacokinetics of Erlotinib

The aim of our study was to investigate the effects of single-dose Ougan (Citrus reticulata cv. Suavissima) juice application on the pharmacokinetics of erlotinib in vivo. Twelve Sprague-Dawley rats were randomly divided into the Ougan juice and control groups (n = 6 each). The rats were given a single dose of 1 mL/100 g Ougan juice or 1 mL/100 g normal saline (NS) by intragastric administration, followed by a single oral administration of 20 mg/kg erlotinib. The plasma concentration of erlotinib in rats was determined using ultra performance liquid chromatography–tandem mass spectrometry (UPLC-MS/MS). Erlotinib-d6 was used as the internal standard for chromatographic analysis on the UPLC BEH C18 analysis column (2.1 mm × 50 mm, 1.7 μm). The mobile phase was composed of acetonitrile and 0.1% formic acid eluting by gradient. Different pharmacokinetic (PK) parameters of erlotinib were calculated. The Ougan juice promoted the absorption of erlotinib and reduced the clearance of the drug. The area under the curve of erlotinib in the single-dose Ougan juice pretreatment group was approximately 1.87 times higher, and the maximum blood concentration (Cmax) was approximately 1.34 times higher than that in the control group. The mean residence time of erlotinib in the Ougan juice group was larger, and the clearance rate was smaller than those in the control group; the difference was statistically significant (P < 0.05). Ougan juice affected the PK spectrum of erlotinib in rats by improving the bioavailability of the drug and significantly increasing its plasma concentration.

Pharmacotherapy for Weight Loss in Cirrhosis and Liver Transplantation: Translating the Data and Underused Potential

BACKGROUND AND AIMS

Thirty percent of patients with cirrhosis are obese and the prevalence of obesity increases after transplant to >40% post-transplant. There are currently four weight loss medications approved by the FDA for treatment of obesity (orlistat, phentermine-topiramate, naltrexone-bupropion, and liraglutide). The aim of this review was to investigate the data on the use of these weight loss medications and alternative medicines in patients with cirrhosis and in liver transplant recipients (LTRs).

APPROACH AND RESULTS

While there is paucity of data for these medications in patients with cirrhosis and LTRs, Liraglutide appears to be generally safe in view of its pharmacokinetic properties. Phentermine-topiramate seems to have the highest weight loss potential but special consideration should be given to neuropsychiatric disorders, cardiovascular comorbidities, and drug interactions. There are emerging data on use of alternative medicines for weight loss but more data are needed.

CONCLUSIONS

The use of weight loss medications is feasible in this patient population but the decision of which medication to prescribe should be individualized based on the degree of renal and hepatic impairment, other co-morbidities, and concomitant medications.

Potential Cytochrome P450-mediated pharmacokinetic interactions between herbs, food, and dietary supplements and cancer treatments

Herbs, food and dietary supplements (HFDS), can interact significantly with anticancer drug treatments via cytochrome p450 isoforms (CYP) CYP3A4, CYP2D6, CYP1A2, and CYP2C8. The objective of this review was to assess the influence of HFDS compounds on these cytochromes. Interactions with CYP activities were searched for 189 herbs and food products, 72 dietary supplements in Web of Knowledge® databases. Analyses were made from 140 of 3,125 clinical trials and 236 of 3,374 in vitro, animal model studies or case reports. 18 trials were found to report direct interactions between 9 HFDS with 8 anticancer drugs. 21 HFDS were found to interact with CYP3A4, a major metabolic pathway for many anticancer drugs. All 261 HFDS were classified for their interaction with the main cytochromes P450 involved in the metabolism of anticancer drugs. We provided an easy-to-use colour-coded table to easily match potential interactions between 261 HFDS and 117 anticancer drugs.

Research Progress of Herbal Medicines on Drug Metabolizing Enzymes: Consideration Based on Toxicology

The clinical application of herbal medicines is increasing, but there is still a lack of comprehensive safety data and in-depth research into mechanisms of action. The composition of herbal medicines is complex, with each herb containing a variety of chemical components. Each of these components may affect the activity of metabolizing enzymes, which may lead to herb-drug interactions. It has been reported that the combined use of herbs and drugs can produce some unexpected interactions. Therefore, this study reviews the progress of research on safety issues caused by the effects of herbs on metabolizing enzymes with reference to six categories of drugs, including antithrombotic drugs, non-steroidal anti-inflammatory drugs, anti-diabetic drugs, statins lipid-lowering drugs, immunosuppressants, and antineoplastic drugs. Understanding the effects of herbs on the activity of metabolizing enzymes could help avoid the toxicity and adverse drug reactions resulting from the co-administration of herbs and drugs, and help doctors to reduce the risk of prescription incompatibility.

Pharmacokinetic herb-drug interaction between ginger and crizotinib

The use of complementary and alternative medicine at least once during or after cancer treatment has increased over the past years from an estimated 25% in the 1970s and 1980s to more than 32% in the 1990s and to 49% after 2000. The risk of herb-drug interaction is therefore increasingly recognized as a public health problem. To the best of our knowledge, we report here the first case of interaction between ginger and anticancer drug, with serious consequences for the patient. There is an urgent need regarding complementary and alternative medicine: Both clinicians and patients should be aware of the potential interactions between herbs and prescribed drugs.

Effect of Pomelo Juice on the Pharmacokinetics of Simvastatin, CYP3A2 Activity and Mdr1a, Mdr1b and Slc21a5 Expressions in Rats

Background: Food-drug interaction can decrease drug effectiveness or increase risk of drug toxicity. Simvastatin is widely used for treatment of hypercholesterolemia and hypertriglyceridemia. Therefore, this study aimed to investigate the effects of pomelo juice on the pharmacokinetics of simvastatin, CYP3a2 activity and Mdr1a, Mdr1b and Slc21a5 expressions in rats. Methods: Rats were divided into 4 groups including (i) control, (ii) pomelo that received pomelo juice orally twice daily for 7 days, (iii) simvastatin that received simvastatin on day 8, and (iv) simvastatin + pomelo juice. Plasma concentrations of simvastatin and simvastatin acid were analyzed using LC-MS/MS. Hepatic CYP3a2 activity was evaluated using midazolam hydroxylation assay. The expressions of hepatic and intestinal Mdr1a, Mdr1b and Slc21a5 were measured using the real-time RT-PCR. Results: Oral administration of pomelo juice for 7 days altered pharmacokinetic profiles of simvastatin and its primary active metabolite, simvastatin acid, in rats. Real-time RT-PCR analysis revealed that pomelo juice significantly suppressed the expression of intestinal Mdr1a and Mdr1b and hepatic Slc21a5. Rat hepatic CYP3a2 catalytic activity was also inhibited following pomelo juice administration. Conclusion: The results of this study suggested that there was a risk of potential drug interaction associated with inhibition of drug transporters and CYP3A caused by pomelo juice.

The effect of Curcumin/Turmeric on blood pressure modulation: A systematic review and meta-analysis

BACKGROUND AND AIM

Hypertension is a chronic condition that can lead to several health problems, such as cardiovascular diseases, myocardial infarction, stroke, retinopathy and renal failure. In the present study, a systematic review and meta-analysis was undertaken with the main aim of estimating the quantitative effect of curcumin/turmeric supplementation on blood pressure (BP).

METHODS

A systematic search was undertaken in Medline, Embase, Scopus, ISI Web of Science, Google Scholar and Cochrane library up to May 2019 to identify randomized clinical trials assessing the effect of curcumin/turmeric on systolic BP (SBP) and diastolic BP (DBP). A random-effects model was used to analyze the impact of combined trials. Cochrane Risk of Bias Tool was applied to assess potential risks of bias.

RESULTS

A total of 11 studies comprising 734 participants were eligible and included in the meta-analysis to estimate pooled effect size. Results of the meta-analysis did not indicate any significant effect of curcumin/turmeric on SBP (-0.69 mmHg; 95% CI: -2.01, 0.64; I² = 18%) and DBP (0.28 mmHg; 95% CI: -1.12, 1.68; I² = 53%). However, subgroup analysis revealed a significant reduction only in SBP levels (-1.24 mmHg; 95% CI: -2.26, -0.22; I² = 0%) but not DBP (0.29 mmHg; 95% CI: -0.65, 1.22; I² = 1%) in studies with ≥12-week supplementation. No favorable effect of curcumin administration on SBP or DBP levels was found after stratification according to either participant's condition or type of intervention (turmeric, crude curcumin and high-absorption curcumin).

CONCLUSION

The present meta-analysis suggests that consuming curcumin/turmeric may improve SBP when administered in long durations. However, more studies are needed to confirm these results.

Reduction of exposure to tacrolimus trough level variability is associated with better graft survival after kidney transplantation

PURPOSE

High tacrolimus trough drug level variability was found to be associated with reduced graft survival. The primary goal of this study was to find whether reduction of exposure to high tacrolimus trough level variability in patients in which previously had high variability was associated with better graft survival.

METHODS

All tacrolimus drug level values in patients that underwent kidney transplantation at our center between 2006 and 2015 were collected. Exposure to variability was calculated using a time-weighted coefficient of variability (TWCV). Time-dependent univariate and multivariate Cox proportional hazard models were used to analyze the primary outcome of graft survival and to determine a cutoff value for TWCV as a predictor of this outcome.

RESULTS

A total of 878 patients were included in the study with a median follow-up of 1263 days. TWCV above 25% was significantly associated with reduced graft survival (HR3.66, 95% CI 2.3-5.8, p < 0.001). Of the 480 patients (54.7%) who had a cumulative TWCV of > 25% at a certain time during the follow-up, 110 (22.9%) later returned to a cumulative TWCV of less than 25%. Reduction of TWCV to values below 25% was associated with a hazard of graft loss that was not different from patients who had cumulative TWCV of less than 25% during the entire follow-up period (HR 1.81, 95% CI 0.71-4.62, p = 0.218 and HR 1.08, 95% CI 0.39-2.99, p = 0.780) in univariate and multivariate analyses, respectively.

CONCLUSIONS

Monitoring TWCV can help detect the high-risk patients. Interventions intended to reduce variability on long-term graft survival may have a positive effect on graft survival.

Efficacy of curcumin/turmeric on liver enzymes in patients with non-alcoholic fatty liver disease: A systematic review of randomized controlled trials

Background

Several studies reported that curcumin supplementation could improve non-alcoholic fatty liver disease (NAFLD). The aim of this study was to evaluate the efficacy of curcumin/turmeric supplementation on liver enzymes in patients with NAFLD.

Methods

PubMed, Scopus, Web of Science and Google Scholar were systematically searched until December 2017. We included randomized controlled trials (RCTs) which examined effect of curcumin/turmeric supplementation on NAFLD in adult participants. Main outcome was alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Potential risks of bias (ROB) were assessed by using Cochrane ROB tool.

Results

All included studies showed low ROB in most of item of Cochrane ROB tool. Meta-analysis of 4 randomized controlled trials including 228 subjects showed a trend toward significant reduction of ALT blood concentrations in subgroup with ≥1000 mg/day curcumin supplementation (–11.36 IU/L, 95% CI: –22.75 to 0.02; I²:51%). Meta-analysis showed a significant reduction of AST in studies with 8-weeks administration (–9.22 IU/L, 95% CI: –12.77 to –5.67; I²: 49%).

Conclusion

This review suggests that curcumin/turmeric might have a favorable effect on NAFLD in higher dosage. Further high-quality studies with large-scale and higher dosage are warranted.

Food-drug interactions precipitated by fruit juices other than grapefruit juice: An update review

This review addressed drug interactions precipitated by fruit juices other than grapefruit juice based on randomized controlled trials (RCTs). Literature was identified by searching PubMed, Cochrane Library, Scopus and Web of Science till December 30 2017. Among 46 finally included RCTs, six RCTs simply addressed pharmacodynamic interactions and 33 RCTs studied pharmacokinetic interactions, whereas seven RCTs investigated both pharmacokinetic and pharmacodynamic interactions. Twenty-two juice-drug combinations showed potential clinical relevance. The beneficial combinations included orange juice-ferrous fumarate, lemon juice-^99mTc-tetrofosmin, pomegranate juice-intravenous iron during hemodialysis, cranberry juice-triple therapy medications for H. pylori, blueberry juice-etanercept, lime juice-antimalarials, and wheat grass juice-chemotherapy. The potential adverse interactions included decreased drug bioavailability (apple juice-fexofenadine, atenolol, aliskiren; orange juice-aliskiren, atenolol, celiprolol, montelukast, fluoroquinolones, alendronate; pomelo juice-sildenafil; grape juice-cyclosporine), increased bioavailability (Seville orange juice-felodipine, pomelo juice-cyclosporine, orange-aluminum containing antacids). Unlike furanocoumarin-rich grapefruit juice which could primarily precipitate drug interactions by strong inhibition of cytochrome P450 3A4 isoenzyme and P-glycoprotein and thus cause deadly outcomes due to co-ingestion with some medications, other fruit juices did not precipitate severely detrimental food–drug interaction despite of sporadic case reports. The extent of a juice-drug interaction may be associated with volume of drinking juice, fruit varieties, type of fruit, time between juice drinking and drug intake, genetic polymorphism in the enzymes or transporters and anthropometric variables. Pharmacists and health professionals should properly screen for and educate patients about potential adverse juice-drug interactions and help minimize their occurrence. Much attention should be paid to adolescents and the elderly who ingest medications with drinking fruit juices or consume fresh fruits during drug treatment. Meanwhile, more researches in this interesting issue should be conducted.

Critical evaluation of causality assessment of herb-drug interactions in patients

The aim of this review was to assess the severity of adverse drug reactions (ADRs) due to herb-drug interactions (HDI) in patients taking herbs and prescribed medications based on published evidence. Electronic databases of PubMed, the Cochrane Library, Medline and Scopus were searched for randomized or nonrandomized clinical studies, case-control and case reports of HDI. The data were extracted and the causal relationship of ADRs as consequences of HDI assessed using Horn's drug interaction probability scale or Roussel Uclaf Causality Assessment Method scoring systems. The mechanism of interaction was ascertained using Stockley's herbal medicine interaction companion. Forty-nine case reports and two observational studies with 15 cases of ADRs were recorded. The majority of the patients were diagnosed with cardiovascular diseases (30.60%), cancer (22.45%) and renal transplants (16.32%) receiving mostly warfarin, alkylating agents and cyclosporine, respectively. HDI occurred in patients resulting in clinical ADRs with different severity. Patients may poorly respond to therapeutic agents or develop toxicity due to severe HDI, which in either scenario may increase the cost of treatment and/or lead to or prolong patient hospitalization. It is warranted to increase patient awareness of the potential interaction between herbs and prescribed medicines and their consequences to curb HDI as a potential health problem.

Association of the combination of time-weighted variability of tacrolimus blood level and exposure to low drug levels with graft survival after kidney transplantation

Background

The variability of tacrolimus blood levels has been shown to be associated with inferior graft survival. However, the effect of variability during the early post-transplantation period has not been evaluated. We sought to evaluate the association between time-weighted variability in the early post-transplantation period and graft survival. We also explored the interaction between drug level variability and exposure to inadequate drug levels.

Methods

This retrospective cohort study included all patients who underwent kidney transplantation in the Rabin Medical Center and were treated with tacrolimus. Time-weighted coefficient of variability (TWCV) was defined as time-weighted standard deviation divided by the mean drug level. Univariate and multivariate Cox proportional hazard model was used with the primary outcome of patients and graft survival.

Results

The study population included 803 patients who underwent kidney transplantation between 1 January 2000 and 29 September 2013. The high tertile of TWCV of tacrolimus blood levels was associated with reduced graft survival by univariate and multivariate analyses [hazard ratio (HR) 1.69, 95% confidence interval (CI) 1.14-2.53, P = 0.01 and HR 1.74, 95% CI 1.14-2.63, P = 0.01, respectively]. The interaction between high TWCV and exposure to inadequately low drug levels was significantly associated with reduced survival (P = 0.004), while the interaction between TWCV and high drug blood levels was not. One hundred and thirty patients (16.2%) had the combination of high TWCV and exposure to low drug values (<5 ng/mL). These patients had reduced graft survival by univariate and multivariate analyses (HR 2.42, 95% CI 1.57-3.74, P < 0.001 and HR 2.6, 95% CI 1.65-4.11, P < 0.001, respectively).

Conclusions

The combination of high TWCV and exposure to low drug levels might identify high-risk patients in the early post-transplantation period.

Nutritional Therapy in Liver Transplantation

Protein-energy malnourishment is commonly encountered in patients with end-stage liver disease who undergo liver transplantation. Malnutrition may further increase morbidity, mortality and costs in the post-transplantation setting. The importance of carefully assessing the nutritional status during the work-up of patients who are candidates for liver replacement is widely recognized. The metabolic abnormalities induced by liver failure render the conventional assessment of nutritional status to be challenging. Preoperative loss of skeletal muscle mass, namely, sarcopenia, has a significant detrimental impact on post-transplant outcomes. It is essential to provide sufficient nutritional support during all phases of liver transplantation. Oral nutrition is preferred, but tube enteral nutrition may be required to provide the needed energy intake. Herein, the latest currently employed perioperative nutritional interventions in liver transplant recipients are thoroughly illustrated including synbiotics, micronutrients, branched-chain amino acid supplementation, immunonutrition formulas, fluid and electrolyte balance, the offering of nocturnal meals, dietary counselling, exercise and rehabilitation.

Curcumin as a clinically-promising anti-cancer agent: pharmacokinetics and drug interactions

INTRODUCTION

Curcumin has been extensively studied for its anti-cancer properties. While a diverse array of in vitro and preclinical research support the prospect of curcumin use as an anti-cancer therapeutic, most human studies have failed to meet the intended clinical expectation. Poor systemic availability of orally-administered curcumin may account for this disparity. Areas covered: This descriptive review aims to concisely summarise available clinical studies investigating curcumin pharmacokinetics when administered in different formulations. A critical analysis of pharmacokinetic- and pharmacodynamic-based interactions of curcumin with concomitantly administered drugs is also provided. Expert opinion: The encouraging clinical results of curcumin administration are currently limited to people with colorectal cancer, given that sufficient curcumin concentrations persist in colonic mucosa. Higher parent curcumin systemic exposure, which can be achieved by several newer formulations, has important implications for optimal treatment of cancers other than those in gastrointestinal tract. Curcumin-drug pharmacokinetic interactions are also almost exclusively in the enterocytes, owing to extensive first pass metabolism and poor curcumin bioavailability. Greater scope of these interactions, i.e. modulation of the systemic elimination of co-administered drugs, may be expected from more-bioavailable curcumin formulations. Further studies are still warranted, especially with newer formulations to support the inclusion of curcumin in cancer therapy regimens.

Practical Recommendations for Long-term Management of Modifiable Risks in Kidney and Liver Transplant Recipients: A Guidance Report and Clinical Checklist by the Consensus on Managing Modifiable Risk in Transplantation (COMMIT) Group

Short-term patient and graft outcomes continue to improve after kidney and liver transplantation, with 1-year survival rates over 80%; however, improving longer-term outcomes remains a challenge. Improving the function of grafts and health of recipients would not only enhance quality and length of life, but would also reduce the need for retransplantation, and thus increase the number of organs available for transplant. The clinical transplant community needs to identify and manage those patient modifiable factors, to decrease the risk of graft failure, and improve longer-term outcomes.COMMIT was formed in 2015 and is composed of 20 leading kidney and liver transplant specialists from 9 countries across Europe. The group's remit is to provide expert guidance for the long-term management of kidney and liver transplant patients, with the aim of improving outcomes by minimizing modifiable risks associated with poor graft and patient survival posttransplant.The objective of this supplement is to provide specific, practical recommendations, through the discussion of current evidence and best practice, for the management of modifiable risks in those kidney and liver transplant patients who have survived the first postoperative year. In addition, the provision of a checklist increases the clinical utility and accessibility of these recommendations, by offering a systematic and efficient way to implement screening and monitoring of modifiable risks in the clinical setting.

Acute Calcineurin Inhibitor Nephrotoxicity Secondary to Turmeric Intake: A Case Report

Tacrolimus, also known as FK-506, is a potent immunosuppressant agent with a host of drug-drug and food-drug interactions. We present the first case of a probable food-drug interaction between the herb turmeric and tacrolimus leading to acute calcineurin inhibitor nephrotoxicity. A 56-year-old man with a history of orthotopic liver transplantation presented to the emergency department from the clinic with worsening edema in the setting of an elevated creatinine level of 4.2 mg/dL. Before the current presentation, the patient had been recently discharged on a previously tolerated low-dose regimen of tacrolimus with a whole-blood tacrolimus level within the desired range. Tacrolimus level on the day of re-hospitalization was elevated to 29.9 ng/mL in the absence of any changes to the patient's medication regimen. On further prompting, the patient identified recent high-dose intake of turmeric with his food. Tacrolimus was held from the patient's medication regimen, and he was discharged on hospital day 4 with objective evidence of improving renal function. Our report builds on the previous studies that described the effects of turmeric or its active ingredient on the pharmacokinetics of tacrolimus. The appropriate reconciliation of herbal agents such as turmeric can be worthwhile in patients with unexplained changes in tacrolimus levels.

Non-Sink Dissolution Behavior and Solubility Limit of Commercial Tacrolimus Amorphous Formulations

An increasing number of drugs with low aqueous solubility are being formulated and marketed as amorphous solid dispersions because the amorphous form can generate a higher solubility compared to the crystalline solid. The amorphous solubility of a drug can be determined experimentally using various techniques. Most studies in this area investigate the drug in its pure form and do not evaluate any effects from other formulation ingredients. In this study, we use 6 marketed amorphous oral drug products, capsules containing 5 mg of tacrolimus, and various excipients, consisting of 1 innovator product and 5 generics. The amorphous solubility of tacrolimus was evaluated using different techniques and was compared to the crystalline solubility of the drug. Dissolution of the different products was conducted under non-sink conditions to compare the maximum achieved concentration with the amorphous solubility. Diffusion studies were performed to elucidate the maximum flux across a membrane and to evaluate whether there was any difference in the thermodynamic activity of the drug released from the formulation and the pure drug. The amorphous solubility of tacrolimus was found to be a factor of 35 higher than the crystalline solubility. The maximum concentration obtained after dissolution of the capsule contents in non-sink conditions was found to match the experimentally determined amorphous solubility of the pure drug. Furthermore, the membrane flux of tacrolimus following dissolution of the various formulations was found to be similar and maximized. This study demonstrates a link between key physicochemical properties (amorphous solubility) and in vitro formulation performance.

New strategy of tacrolimus administration in animal model based on tacrolimus-loaded microspheres

New strategies for tacrolimus administration that conserve its immunosuppressive effect but avoiding fluctuations in tacrolimus circulating levels are needed. The aim was to analyze if subcutaneous biodegradable tacrolimus-loaded microspheres injection promoted a significant immunosuppressive response in rats. Rats received two subcutaneous tacrolimus-loaded microspheres injections at different days, the first injection was done at day 0 and the second injection was done 12 days after. Plasma circulating levels of tacrolimus, interleukin-2 (IL-2) and calcineurin phosphatase (PP2B) activity in mononuclear cells were measured. Tacrolimus plasma levels were significantly increased from the day after tacrolimus-loaded microspheres injection and remained increased during 10days. Compared to control, plasma IL-2 levels and PP2B activity in mononuclear cells were significantly decreased during ten days. At day 12, a new subcutaneous injection of tacrolimus-loaded microspheres was performed and two days after injection, tacrolimus plasma levels were again increased and both IL-2 plasma levels and PP2B activity decreased. A single subcutaneous tacrolimus-loaded microspheres injection was enough to reduce tacrolimus-related immunosuppressive parameters. These results open the possibility of new therapeutic strategies to administrate calcineurin inhibitors reducing the variability of their circulating levels related to gastrointestinal drug absorption/metabolism modifications.

Within-patient variability in immunosuppressive drug exposure as a predictor for poor outcome after transplantation

Within-patient variability in immunosuppressive drug exposure is easily identified by measurement of drug concentrations at the outpatient clinic. Fluctuating levels despite a stable drug dose can be observed in a substantial proportion of patients. It has now been shown that this within-patient variability is a predictor for poor long-term outcome after transplantation. Nonadherence most likely is an important determinant of variability, and strategies to tackle nonadherence are being developed.

Intra-patient variability in tacrolimus exposure: causes, consequences for clinical management

Tacrolimus (Tac) is widely used for the prevention of rejection after solid organ transplantation. Finding the optimal balance between effective Tac concentrations and toxicity is a challenge and requires therapeutic drug monitoring. In addition to the well-known inter-patient variability, the clinical use of Tac is also complicated by considerable intra-patient variability (IPV) in Tac exposure. Tac IPV is defined as the amount of fluctuation of whole-blood concentrations over a certain period of time during which the Tac dose remains unchanged. A high IPV in Tac exposure has recently been recognized as a strong risk factor for acute rejection and poor long-term kidney transplantation outcome. In addition to non-adherence, several other factors determine the magnitude of the IPV in Tac exposure. Quantification of IPV is easy and can be easily incorporated into everyday clinical practice as a tool for optimizing transplantation outcomes.