Food & Drug Interactions and Precautions Teaching Plan To use this lesson for self-study, the learner should read the materials, do the activity, and take the test. For group study, the leader should give every learner a copy of the learning guide and use the suggested activities to teach the lesson. Objectives Participants in this activity will be able to: Describe foods and medications that should not be mixed. Recognize possible signs of food/drug interactions. Apply knowledge of food/drug interactions and precautions when assisting with medication administration and food preparation. Prepare the Lesson Bring copies of completed medication records used for clients in your organization. Either remove any identifying information from the records or be sure they do not leave the building. Create Readiness to Learn Ask participants if they have ever experienced or observed a drug reaction or side effect. If so, ask them to tell about the experience. Most people have had some kind of food and/or drug interaction, although they may not realize it. If they have ever taken tetracycline, Cipro, or iron with milk, for example, they have hindered the effectiveness of the medication and not received the full benefit of the drug. Point out that food/drug interactions are common and cause problems ranging from ineffective medication all the way to serious illness and even death. Tell the participants the objectives of the lesson. The Lesson Deliver a short lecture summarizing the main issues in food/drug interactions, based on the material in the learning guide. Ask participants to work in pairs. Give each pair at least one of the medication records copied before class. Instruct participants to work together to discover if any of the medications on their records would interact with any foods. They should refer to the charts and other material in the learning guide for assistance. After participants have had enough time to examine all the medications on their records for interactions with foods, ask them to tell the rest of the group what they discovered. Discuss the implications for your organization s medication procedures. Conclusion Have the learners take the test, and then grade the test together. Hand out certificates to those who answer at least 70% correctly (7 out of 10). Test Answers: 1. True; 2. the elderly, those with cancer, those with liver or kidney disorders, those with gastrointestinal disorders, those who drink alcohol; 3. True; 4. False; 5. blood pressure; 6. cheese, sausage, sauerkraut, coffee; 7. bananas, orange juice, potatoes, green leafy vegetables; 8. two; 9. alcohol; 10. excitability, rapid heartbeat, headache. Food & Drug Interactions and Precautions Page 1 of 11
Food & Drug Interactions and Precautions Be Drug-Smart Learning Guide There are times when foods interact with drugs by making the drugs less effective or more powerful, or by triggering unwanted side effects. This lesson will help you avoid mixing common drugs with foods that can cause problems. Food/drug interactions tend to be unpredictable because people vary in their responses to medications and no two people eat exactly the same diet. Those at greatest risk for an interaction are: How Food Affects Medicine The elderly, who are likely to take one or more types of medication and have other health and nutrition problems People with liver or kidney disorders People with cancer People with gastrointestinal disorders People who drink alcohol Many medications need to be taken with meals for several reasons. Some medications, such as aspirin and ibuprofen, can irritate the lining of the stomach. Other medicines, including some blood pressure drugs and water pills, work better on a full stomach. Even though a meal can protect the stomach from some medications and boost the effectiveness of others, it can cause difficulties with absorption. For example, the drug Fosamax (for brittle bones) is drastically affected by food. It must be taken first thing in the morning with plain water, on an empty stomach, at least 30 minutes before consuming any food, beverage, or medications. Even coffee and orange juice hinder its absorption. The amount of food in the stomach when a person takes a medication can influence the amount of medicine absorbed and the time it takes to reach the bloodstream. Some drugs should be taken on an empty stomach so there is nothing to interfere with the breakdown of the medicine or slow its delivery. Food & Drug Interactions and Precautions Page 2 of 11
Foods Containing Caffeine Coffee, cola, tea, and chocolate can cause problems if they are taken with certain medications. The caffeine from these foods can cause symptoms of caffeine overdose, such as excitability, rapid heartbeat, and headache, when taken with drugs that contain caffeine. It is wise to avoid caffeine if a person is taking certain medicines, since caffeine can raise blood pressure. People taking the drug theophylline (for asthma) should avoid foods containing caffeine. Both theophylline and caffeine are stimulants. Charcoal-Broiled Meats These can decrease the effectiveness of some drugs, such as theophylline. Fruit Juices Grapefruit Juice Drinking grapefruit juice with some drugs may block the release of stomach enzymes that help the body absorb the drugs. Taking grapefruit juice also slows the breakdown of certain drugs by the liver. This can cause the medicine to build up in the system, creating increased blood levels that may lead to side effects. The amount of the medication that enters one s system may be more or less than is really needed, which could have negative effects. A person taking the following drugs should avoid grapefruit juice for at least 2 hours before and after taking them: Norvasc, Cardizem, Procardia, Plendil, or Adalat (for high blood pressure or angina) Lipitor, Zocor, or Pravachol (to lower cholesterol) Antihistamines such as Hismanal (for allergies) Xanax and Halcion (for anxiety) Estrogens (female hormones) Invirase (for HIV and AIDS) Sandimmune and Prograf (to prevent transplanted organ rejection) Cranberry Juice Cranberry juice can slow down the action of Valium, a medicine given to reduce anxiety. It may also increase the excretion of Valium from the body. As a result, cranberry juice can reduce the drug s calming effect. Other Fruit Juices and Acidic Foods People taking the antibiotics penicillin or erythromycin should avoid acidic foods because they cause the drugs to break down too fast, making them less effective. Check the chart on Highly Acidic Foods to see what to avoid. Food & Drug Interactions and Precautions Page 3 of 11
Highly Acidic Foods to Avoid When Taking Penicillin or Erythromycin Condiments and Seasonings Vinegar Pickles: sweet, dill, or sour Fermented olives Mayonnaise Dairy Products Yogurt Sweeteners Fruit jellies Fruit jams Beverages Ginger ale Lime juice Lemon juice Wines Cranberry juice Cider Grapefruit juice Currant juice Orange juice Apple juice Pineapple juice Prune juice Tomato juice Vegetables and Beans Sauerkraut Cucumbers Tomatillo Fruit Lemons and limes Apricots Cranberries, cranberry sauce Gooseberries Raisins Oranges Plums Rhubarb Apples, apple sauce, crab apples Raspberries Grapefruit Boysenberries Kiwi, Quince Strawberries Blackberries Kumquat, Loquat Fruit cocktail Blueberries Pineapple Foods that Contain Calcium (Milk, Yogurt, Cheese) The calcium in dairy products binds to and inhibits the absorption of some medications, such as iron and the antibiotics tetracycline and Cipro. As a result, less medicine is absorbed and it may not work. Take iron, Cipro, and all tetracycline derivatives at least 2 hours before or 2 hours after consuming any dairy products. There is one exception: dairy products do not affect the antibiotic doxycycline, which comes from tetracycline. Orange juice with calcium can have the same effect as dairy products. In one test, calcium-fortified orange juice reduced the level of Cipro in the blood by 40%. Some antacids contain calcium. Medications like Cipro, tetracycline, and iron should be taken at least 2 hours before or 6 hours after taking antacids. Food & Drug Interactions and Precautions Page 4 of 11
Alcohol Avoid alcohol when taking: Claritin or Zyrtec (for allergies), because alcohol may increase drowsiness. Prozac, Zoloft, Paxil (antidepressants), because alcohol may increase drowsiness, dizziness, and depression. Insulin, Glucophage, or Glucotrol XL (for diabetes), because alcohol combined with these drugs may cause a rapid drop in blood sugar. Coumadin (a blood thinner), because alcohol may increase the drug s effect and cause bleeding. Lipitor, Zocor, or Pravachol (to decrease cholesterol), because alcohol may cause liver damage. Ambien (for insomnia), because alcohol may increase drowsiness. Potassium-Rich Foods and Salt Substitutes Foods rich in potassium, and salt substitutes that contain potassium, should be encouraged in people that take certain kinds of diuretics (water pills). Potassium-rich foods and salt substitutes should be avoided, however, in people who take other diuretics and certain types of drugs to lower blood pressure. Diuretics are drugs that increase the rate of urine flow, thereby decreasing the amount of water and salt in the body and lowering blood pressure. Diuretics such as hydrochlorothiazide, Lasix, and Bumex may wash potassium out of the body. Eating plenty of potassium-rich foods such as bananas, orange juice, potatoes, and green leafy vegetables can prevent the body s potassium level from dropping too low. Some diuretics do not wash potassium from the body and may even block potassium loss. The danger with these drugs is that too much potassium can build up, which can alter the heart s rhythm and cause weakness. People that take this kind of diuretic should avoid potassium-rich foods and salt substitutes containing potassium. Other kinds of medicines used to treat high blood pressure can also cause heart problems if there is too much potassium in the diet. Examples of blood pressure drugs and diuretics that should not be taken with diets high in potassium include: ACE inhibitors (Accupril, Lotensin, Prinivil) Aldactazide Altace Amiloride Capoten Dyazide Dyrenium (triamterene) Maxzide Midamor Moduretic Spirozide (spironolactone) Vasotec Food & Drug Interactions and Precautions Page 5 of 11
How do you know which kind of medication a person is taking, and which foods to encourage or avoid? Read the labels Check the medication record Ask the doctor, pharmacist, or nurse Read the written material with the drug Medicines with Special Food Requirements Some medications have very specific requirements for foods to take or foods to avoid. Coumadin (warfarin--thins the blood to prevent blood clots) Avoid large amounts (small amounts are OK) of asparagus, broccoli, cabbage, cauliflower, kale, lettuce, liver, onions, spinach, turnip greens, egg yolk, green tea, and soybean oil. Eating too many foods high in vitamin K, such as these, may undesirably increase blood clotting. Large doses of vitamin E can increase the effects of the drug too much, possibly causing excessive bleeding. Isoniazid (used to treat tuberculosis) Avoid tuna, sauerkraut, and yeast extract. These can lead to headache, heart palpitations, flushing, and diarrhea. Sinemet (levodopa used to treat Parkinson s disease) Avoid high-protein foods (meat, fish, and eggs). These foods can reduce the effectiveness of the medication. Synthroid (for low thyroid hormone levels) Avoid a high-fiber diet and soy products, which might decrease the amount of the drug that is absorbed. Don t eat soy products within 4 hours of taking Synthroid or any medication for low thyroid levels. Avoid foods containing large amounts of iodine, such as spinach, shellfish, saltwater fish, and iodized salt. Iodine can affect thyroid hormone levels. Aim for consistent amounts of iodine in the diet. Monoamine Oxydase Inhibitors (MAOIs) (antidepressant drugs) These drugs are given for depression, inability to sleep, panic disorders, and anxiety. They can be dangerous if taken with certain foods. Examples of these medicines are Nardil, Parnate, and Manerix. Tyramine, an amino acid found in various foods, can cause a dangerous rise in blood pressure in persons receiving MAOI therapy. People taking these drugs must avoid foods containing tyramine (see chart). Food & Drug Interactions and Precautions Page 6 of 11
Foods Containing Tyramine to Be Avoided or Used with Caution by Persons Receiving MAOI Therapy Smoked, fermented, or pickled herring Aged fish, meat, or spoiled food Sausage, bologna, pepperoni, salami (ham is OK) Soups with protein extracts (most soups) Yeast vitamin supplements or yeast extracts that are spread on bread or mixed with water. Yeast used in baking is safe. Cheese, sour cream, yogurt (cottage and cream cheese are OK) Spinach in large amounts Alcohol (beer, ale, wine, vermouth, whiskey, liqueurs) Alcohol-free beer and wines Broad (Fava) bean pods Chocolate in large amounts Coffee, tea, colas Bean curd Nuts in large quantities Sauerkraut Ginseng Avocados (particularly overripe) What you should remember about food-drug interactions: Medicine should usually be taken with a full glass of plain water. Never stir medicine into food or take capsules apart, unless the physician has ordered it this way and the pharmacist has approved it. Mixing medicine with food or taking capsules apart may change the way the drug works. Do not mix medications into hot drinks. The heat from the drink may destroy the drug. Medicine should never be taken with alcoholic drinks. Vitamin pills should usually not be taken at the same time as other medications. Vitamins and minerals can interact with some drugs. A person s pharmacist and physician should know about all the medications a person is taking, both prescription and nonprescription. Non-prescription drugs can interact with prescription drugs and change the way one or both medicines affect the person. Labels on packages and containers are meant to be read and followed. If you do not understand something, or think you need more information, ask your supervisor, the nurse, the physician, or the pharmacist. Read directions, warnings, and interaction precautions printed on all medicine labels and package inserts. Even over-the-counter medications can cause problems. Food & Drug Interactions and Precautions Page 7 of 11
Food and Drug Interactions: Quick Reference This drug with these foods can lead to: Accupril (Ace inhibitor, to treat high blood pressure) Salt substitutes containing potassium; large amounts of potassium-rich foods such as bananas, oranges, potatoes, leafy green vegetables May result in increased potassium, which could cause an irregular heartbeat or muscle weakness Achromycin (tetracycline) Dairy products Reduced effectiveness of medicine Altace (ramipril) Salt substitutes containing potassium Heart rhythm problems Ambien Alcohol Increase the drowsiness effect of the drug Antihistamines (Claritin, Grapefruit juice Heart problems Allegra,Benadryl,Hismanal) Capoten (captopril) Salt substitutes containing potassium Heart rhythm problems Cardizem Grapefruit juice Drug levels too high or too low Cipro Dairy products, calcium-containing Reduced effectiveness antacids, orange juice fortified with calcium Coumadin (warfarin) Foods high in vitamin K (leafy green veg.); foods high in vitamin E (onions) Reduced effectiveness of medicine Bleeding problems Cyclosporin Grapefruit juice Confusion and trembling Declomycin Dairy products Reduced effectiveness of medicine Dyazide (triamterene) Salt substitutes containing potassium Heart rhythm problems Eldepryl (selegiline) Tyramine-containing foods Dangerously high blood pressure Erythromycin & Penicillin Acidic foods (citrus fruits & juices, pickles, Reduces effectiveness of medicine tomatoes, vinegar, caffeine) Estrogens Grapefruit juice Problem with absorption or utilization Fosamax Orange juice, coffee, and tea Decreased effectiveness. Take on empty stomach. Halcion (benzodiazepines) Grapefruit juice Drug levels too high or too low Invirase (antiviral for HIV) Grapefruit juice Problem with absorption or utilization Isoniazid Tuna, sauerkraut, yeast extract Headache, palpitations, flushing, diarrhea Larodopa (levodopa High-protein foods (meat, fish, eggs) Reduced effectiveness of medicine Lipitor Grapefruit juice Problem with absorption or utilization Lotensin (ACE inhibitor, to treat high blood pressure) Salt substitutes containing potassium; large amounts of potassium-rich foods May result in increased potassium, which could cause an irregular heartbeat or muscle weakness MAOIs (antidepressants) Tyramine-containing foods Dangerously high blood pressure Marplan (isocarboxazid) Tyramine-containing foods Dangerously high blood pressure Maxzide (triamterene) Salt substitutes containing potassium Heart rhythm problems Moduretic (amiloride) Salt substitutes containing potassium Heart rhythm problems Nardil (phenelzine) (MAOI) Tyramine-containing foods Dangerously high blood pressure Norvasc Grapefruit juice Drug levels too high or too low Orap (pimozide) Grapefruit juice Disturbed heart rhythm Parnate (MAOI) Tyramine-containing foods Dangerously high blood pressure Paxil (antidepressant) Alcohol May increase drowsiness, dizziness, depression Plendil (felodipine) Grapefruit juice Disturbed heart rhythm Pravachol Grapefruit juice Problem with absorption or utilization Prinivil (lisinopril) Salt substitutes containing potassium Heart rhythm problems Procardia Grapefruit juice Drug levels too high or too low Prozac (antidepressant) Alcohol May increase drowsiness, dizziness, depression Sinemet (levodopa) High-protein foods (meat, fish, eggs) Reduced effectiveness of medicine Synthroid (thyroid) High-fiber diet & soy products; large amounts of iodine such as spinach, shellfish, saltwater fish, and iodized salt Problem with absorption or utilization. Iodine can affect thyroid hormone levels. Aim for consistent amounts of iodine in the diet. Theophylline Caffeine Nausea, palpitations, or seizures Xanax (benzodiazepine) Grapefruit juice Drug levels too high or too low Valium Cranberry juice Reduced effectiveness of medicine Vasotec (enalapril) Salt substitutes containing potassium Heart rhythm problems Zocor Grapefruit juice Problem with absorption or utilization Zoloft (antidepressant) Alcohol May increase drowsiness, dizziness, depression Zyvox (linezolid) (antibiotic) Tyramine-containing food Dangerously high blood pressure Food & Drug Interactions and Precautions Page 8 of 11
Food and Drug Interactions and Precautions: Test Name Date Score (Must answer seven questions correctly to pass) 1. Foods may interact with drugs, making the drugs either less effective or stronger. True or False 2. List five groups of people at greater risk for food/drug interactions. 1. 2. 3. 4. 5. 3. Fosamax is greatly affected by food and should be given on an empty stomach. True or False 4. When a person is taking Coumadin all green leafy vegetables should be avoided. True or False 5. Clients on MAOIs should avoid foods containing tyramine because they can cause a dangerous rise in. 6. Choose four foods from the following list that contain tyramine: Cheese All dairy products Sausage Sauerkraut Green leafy vegetables Coffee 7. Name 2 foods high in potassium: and 8. Tetracycline and Cipro should be taken hours before or after consuming any dairy products. 9. People who take Prozac, Zoloft, and other medications for depression should avoid drinking. 10. Symptoms of an overdose of caffeine might include, rapid, and. Food & Drug Interactions and Precautions Page 9 of 11
Certificate of Achievement Presented to (Participant s Name) For completing the 1-hour course Food and Drug Interactions and Precautions Date Organization Presented by Signature of presenter or write self study Food & Drug Interactions and Precautions Page 10 of 11
Medication of the Month Cipro (Ciprofloxacin) Cipro is an antibiotic that kills many types of bacteria, and is used to treat bladder, kidney, prostate, cervical, stomach, intestinal, lung, sinus, bone, and skin infections. It is also the recommended drug for treatment of inhalation anthrax. How supplied Tablets 100mg, 250 mg, 500 mg, and 750mg. Oral Suspension in 5% (5 g ciprofloxacin in 100cc) and 10% (10 g ciprofloxacin in 100cc) strengths. Oral suspension may clog feeding tube, so mix a crushed tablet in water to give through a feeding tube. Neither form is recommended for a jejunostomy tube since absorption in the jejunum is poor. Administration Taken morning and evening. May be taken with or without food. Take Cipro 2 hours before or 2 hours after dairy products. Administer Cipro with water, not milk or juices containing calcium since they reduce absorption. Warnings Serious and fatal reactions have been reported in persons receiving Cipro along with theophylline. Safety and effectiveness in individuals less than 18 years of age (except for post-exposure of inhalation anthrax) has not been established. Drug and Food Interactions Avoid taking the following within 2 hours of taking Cipro: antacids, vitamins, iron supplements, zinc supplements, or sucralfate. They can be taken 2 hours after or 6 hours before Cipro. Giving Cipro with theophylline results in elevated serum theophylline levels and increased risk of a client developing adverse reactions. Cipro may increase the effects of theophylline and caffeine. Caffeine overdose is possible when products containing caffeine are consumed while taking Cipro. Phenytoin (antiepileptic drug) serum levels may be increased or decreased when given with Cipro. Cipro can enhance the effects of the oral blood thinner warfarin (Coumadin). Closely monitor bleeding time when giving Cipro along with blood thinners. Contraindications Should not be given to persons who have ever shown sensitivity or allergy to antibiotics like Cipro (quinolone class). Cipro should be discontinued at the first appearance of a skin rash or any other sign of sensitivity. Precautions Cipro is excreted in human milk. Side Effects Nausea, diarrhea, vomiting, abdominal pain or discomfort, headache, rash, restlessness, abnormal liver enzymes, and/or central nervous system disturbance. Food & Drug Interactions and Precautions Page 11 of 11