Food for thought: Uncovering the complexities of drug–nutrition interactions

Drug–nutrition interactions (DNIs; also sometimes referred to drug–nutrient interactions, food–drug interactions or food–medication interactions) occur commonly because of medication use in relation to food intake and overall individual nutritional status. A DNI may be bidirectional, altering drug therapeutic or adverse effects, as well as nutrient action or nutritional status, including an effect on appetite or the ability to eat.1-3 As a result of DNIs, patients may experience an increase in lab testing and medication utilization, prolonged treatment or hospital stay, and decreased quality of life. Management of DNIs is the responsibility of the interdisciplinary team, which includes the prescriber, pharmacist, dietitian/nutritionist, nurse, occupational and rehabilitation therapists, social worker and other specialists who work together to plan and coordinate the drug regimen, along with diet and nutritional supplements, in order to preserve optimal nutrition status and minimize the impact of DNIs. Pharmacists play a front-line role in detecting and managing DNIs. This article reviews DNI risk factors and mechanisms, and provides examples of DNIs affecting various body systems. It also outlines the pharmacist’s role in suggested DNI management. Risk factors for drug–nutrition interactions Vulnerability to drug-induced nutritional deficiencies is greatest in older adults, patients taking multiple medications and those with chronic illness, multiple co-morbidities, or marginal or inadequate nutrition.4 The number of potential drug interactions increases sharply in people who take five or more drugs concurrently.5 Encountering institutionalized older adults taking 10 or more different drugs on a daily basis is common.6 Other risk factors for DNIs include dehydration, pharmacogenomic polymorphisms, prescribed therapeutic diet, dietary supplements or complementary/alternative medicine use, enteral/parenteral feeding, heavy alcohol intake, substance abuse and medication nonadherence.7 In some cases, adverse effects from drug therapy may not result from a direct pharmacological effect of the drug, but instead occur due to nutritional deficiencies caused by long-term drug exposure.8 Mechanisms of drug–nutrition interactions DNIs may arise due to alterations in movement of a drug (pharmacokinetics) or nutrient (nutrient kinetics) within the body, or by direct modification of drug action (pharmacodynamics) or nutrient action (nutrient dynamics). Examples of both types of interactions and suggested management are shown in Table 1.9-35 Pharmacokinetics Each of the pharmacokinetic parameters (Liberation, Absorption, Distribution, Metabolism and Excretion; LADME) may be affected by a food/nutrient or by patient nutritional status. Likewise, drugs may alter nutrient absorption, metabolism and excretion. Liberation, absorption: A frequently encountered DNI consideration involves whether to take a drug with food or to avoid food intake at the time of drug administration. Most oral prescription medications include information in the product monograph detailing the impact of food intake on absorption, measured in a single-dose preclinical trial, which in turn leads to a manufacturer’s recommendation regarding food intake in relation to a drug. Effects on drug liberation and absorption may be due to alterations in gastric acidity with food intake or bile acid release with high-fat meals. In some cases, recommendations may be very specific (e.g., each dose of lurasidone and ziprasidone should be taken with a >350 kcal or >500 kcal meal, respectively).36,37 Some food intake recommendations are made with the goal of speeding or enhancing overall drug absorption (area under the concentration-time curve [AUC]) for poorly absorbed drugs (e.g., alendronate).38 Others seek to reduce maximal serum concentration (Cmax) to reduce dose-related adverse effects (e.g., felodipine and some other drugs with hypotensive effects)11 or drug-induced gastrointestinal upset.27 DNIs resulting in a chelation reaction involve binding of bivalent/trivalent cation metals in foods, beverages or supplements to a drug. They must be avoided, as they can result in loss of absorption of both the drug and the nutrient (e.g., ciprofloxacin or tetracycline with calcium, iron, magnesium and/or zinc).39,40 Distribution: DNIs affecting drug distribution mostly pertain to alterations in protein binding and free (unbound) fraction of a drug in patients with reduced serum albumin. For highly protein-bound drugs, small absolute decreases in protein binding may translate to large relative increases in free fraction, which can lead to adverse effects and toxicity in some cases; the anticonvulsant phenytoin is the most frequently cited example of this phenomenon.9,10 Metabolism: Ingredients in food and certain natural health products can inhibit drug metabolism via CYP450 enzymes. For example, grapefruit and related fruits (e.g., pummelo, tangelo, Seville oranges, minneolas, clementines, limes and other exotic orange hybrids, but not lemons or ‘regular’ sweet oranges) can inhibit the metabolism of a number of drugs, including ticagrelor.41 Other ingredients (e.g., St. John’s wort, milk thistle) can induce drug metabolism (e.g., rilpivirine) via CYP450 enzymes.42 Excretion: Nutrients (e.g., sodium, potassium) may compete with drugs (e.g., lithium) for tubular reabsorption.24 Other foods or supplements (e.g., cranberry, calcium carbonate) can alter urine pH and increase or decrease excretion of weakly acidic or basic drugs (e.g., amphetamine derivatives).21-23 Nutrient kinetics Drugs may alter nutrient absorption via chelation reactions (e.g., quinolone antibiotics such as ciprofloxacin can be chelated by calcium or iron),37 by adsorption of nutrients to a drug (e.g., cholestyramine may adsorb fat-soluble vitamins)43 or by changing gastric pH (e.g., proton pump inhibitors can cause vitamin B12 malabsorption).19 Drugs can inhibit nutrient metabolism (e.g., isoniazid reduces conversion of pyridoxine to its active form)25 and reduce absorption of fat-soluble vitamins (e.g., orlistat can reduce the absorption of vitamins A, D, E and K).32 Drugs can also induce nutrient metabolism (e.g., carbamazepine induces CYP enzymes responsible for conversion of vitamin D to inactive metabolites).33,34 Perhaps the most well-known DNI, the so-called “cheese effect,” occurs when foods containing high levels of tyramine are consumed by a patient taking an irreversible monoamine oxidase inhibitor (e.g., phenelzine); the excess tyramine displaces norepinephrine from synaptic vesicles, which may result in hypertensive crisis. This is an example of a drug impacting nutrient kinetics by inhibiting nutrient metabolism.44 Drugs can also alter excretion of various nutrients, A well-known example is thiazide diuretics (e.g., hydrochlorothiazide), which can increase potassium, sodium, bicarbonate and chloride excretion, but decrease calcium excretion.45 Table 1: Selected DNIs* and Suggested Management9-35 Body System (Interaction type) Drug Food/nutrient/ supplement/ Nutritional Parameter Interaction Suggested Management CNS (PK DNI) phenytoin alcohol Heavy chronic alcohol use associated with ▼ albumin level can ▲ phenytoin free fraction & lead to toxicity Avoid alcohol if possible; Monitor albumin and phenytoin level (or free/unbound phenytoin level) and adjust phenytoin dose accordingly CNS (PD DNI) felodipine alcohol Alcohol ▼ BP and ▲ lightheadedness Limit alcohol intake (especially near expected Tmax (2.5–5 hr after dose) Oral (PK DNI) asenapine food or drink Water intake within 2–5 min after sublingual tablet administration can ▼absorption Avoid eating/drinking for 10 min after administration Oral (PD DNI) eszopiclone, zopiclone oral intake High rate of dysgeusia (taste disturbance) (▲ with females) may ▼ appetite and nutritional intake Use lowest effective dose; consider alternate hypnotic agent Cardiovascular (PK DNI) dronedarone grapefruit juice ▲ Drug level 200%, ▲ QTc interval and ▲ risk of torsade de pointes Avoid grapefruit/related fruits Cardiovascular (PD DNI) eplerenone potassium Hyperkalemia, ▲ arrhythmia risk Avoid potassium supplements. Caution with salt substitutes or high-potassium foods Respiratory (PK DNI) theophylline grilled meat, cruciferous vegetables (e.g., broccoli, Brussels sprouts, cabbage, cauliflower, radish, and watercress) Polycyclic aromatic hydrocarbons in charred/grilled meat (and cigarette smoke) and phenethyl isothiocyanate (PEITC) and the indole derivative 3,3′-diindolylmethane in cruciferous vegetables ▼ drug level via CYP1A2 reduction Maintain consistent intake of grilled meat, cruciferous vegetables; monitor theophylline level and adjust dose Respiratory (PD DNI) salbutamol caffeine-containing foods Caffeine acts as a mild bronchodilator (similar to theophylline) but may increase jitteriness, ▲ heart rate when taken in combination with beta-2 agonist Limit caffeine intake during salbutamol treatment Gastrointestinal (PK DNI) lansoprazole food intake Absorption ▼ 70% if taken 30 min after food (compared to fasting administration) Take lansoprazole before meals Gastrointestinal (PD DNI) famotidine alcohol, caffeine, peppermint, chocolate, spicy/fried foods These foods ▼ lower esophageal sphincter pressure, ▲ risk of GERD symptoms, counteracting beneficial effects of drug Avoid/limit these foods Genitourinary (PK DNI) dextroamphetamine urinary pH Urinary acidifying agents (e.g., cranberry) ▼ drug level; urinary alkalinizing agents (e.g., calcium carbonate, sodium bicarbonate, antacids) ▲ drug level; may impact efficacy, adverse effects and duration of action Limit foods associated with altered urinary pH or consider alternate treatment (methylphenidate or nonstimulant) Genitourinary (PD DNI) lithium urine specific gravity By inhibiting ability of kidney to form concentrated urine via ADH resistance, lithium may cause polyuria and/or NDI Test for NDI (urine specific gravity, urinary sodium and osmolality, serum sodium and osmolality, water deprivation test) with large increase in urine output and water intake Nutrition (PK DNI) isoniazid pyridoxine (vitamin B6) Isoniazid inhibits enzymatic conversion of pyridoxine to active form and may lead to pyridoxine deficiency, which may result in peripheral neuropathy or seizures Recommend supplementary pyridoxine 10–50 mg daily during isoniazid treatment Nutrition (PD DNI) duloxetine blood glucose Altered glycemic control ▲ hypoglycemia risk in patients with diabetes taking insulin or oral hypoglycemic agents Monitor fasting glucose regularly (especially after duloxetine initiation or dose change); adjust insulin/oral hypoglycemic dose Blood (PK DNI) metformin vitamin B12 Metformin interferes with vitamin B12-intrinsic factor absorption in the terminal ileum and can lead to vitamin B12 deficiency, pernicious anemia and peripheral neuropathy Monitor vitamin B12 level with long-term metformin therapy and consider vitamin B12 supplementation Blood (PD DNI) darbepoietin alfa iron Adequate body iron stores are required for ▲ RBC production Recommend iron supplement with ferritin < 100 µg/L or transferrin saturation < 20%. Skin (PK DNI) apremilast St. John’s wort St. John’s wort induces CYP3A4 and ▼ drug level leading to reduced effectiveness for treatment of psoriasis Avoid St. John’s wort during apremilast treatment Skin (PD DNI) orlistat vitamin E ▼ Absorption of fat-soluble vitamins (E, as well as A, D & K) which may lead to deficiency; symptoms may include dry skin (as well as peripheral neuropathy, ataxia, myopathy, retinopathy and immunosuppression) Recommend multivitamin supplementation, including vitamin E and other fat-soluble vitamins, taken separate from drug by > 2 hr Musculoskeletal (PK DNI) carbamazepine vitamin D, calcium Carbamazepine induces CYP enzymes responsible for vitamin D metabolism leading to ▼ vitamin D level, ▼ calcium, ▼ BMD, osteomalacia and ▲ fracture risk Monitor vitamin D, calcium level and provide vitamin D and calcium supplementation with long-term carbamazepine use. Recommend regular weight-bearing exercise Musculoskeletal (PD DNI) lovastatin red yeast rice Active ingredient in red yeast rice (monacolin K) is structurally identical to lovastatin; ▲ CK and rhabdomyolysis risk Avoid use of red yeast rice with statins *List of interactions is not comprehensive of all possible drug nutrition interactions. Interactions were selected to illustrate different mechanisms of interactions across a variety of drug classes commonly encountered by community pharmacists. Interactions listed in table may not necessarily occur with other drugs in the same pharmacological or therapeutic class. –increase; –decrease Abbreviations: ADH–antidiuretic hormone; BP–blood pressure; BMD–bone mineral density; CK–creatine kinase; CNS–central nervous system; CYP–cytochrome p450; DNI–drug–nutrition interaction; GERD–gastroesophageal reflux disease; NSAIDs–nonsteroidal anti-inflammatory drugs; NDI–nephrogenic diabetes insipidus; QTc–corrected QT interval (on electrocardiogram); RBC–red blood cell; PD–pharmacodynamic; PK–pharmacokinetic; Tmax–time to maximal (peak) serum concentration. Pharmacodynamics Pharmacodynamic DNIs can occur when the drug and food/nutrient exhibit similar effects, thus amplifying the drug effect and potentially leading to toxicity. For example, vitamin E and certain natural supplements (i.e., garlic, ginger, ginseng and ginkgo) have antiplatelet effects that may enhance the anticoagulant effects of warfarin or the direct Factor Xa inhibitor, rivaroxaban.46 Conversely, if a drug and a food/nutrient have opposing effects, increased nutrient intake may lead to loss of drug efficacy, with potentially severe consequences. While used less frequently in recent years due to the availability of newer direct-acting oral anticoagulants, many patients still receive treatment with the vitamin K antagonist, warfarin. High/variable vitamin K intake (most often in the form of leafy green vegetables, although other dietary sources exist) can make adjustment of warfarin dosage very challenging. Increased INRs and risk of bleeding can occur with high or suddenly increased intake of these foods, while decreased INRs and risk of clotting can happen with low or suddenly decreased intake of these foods.47 Poor adherence to a dietary prescription may counteract desired drug effects. For example, failure to follow a prescribed diabetic diet may lead to hyperglycemia, elevated hemoglobin A1C levels and resultant complications, even though a patient is taking their antidiabetic medication. Drug effects on nutritional status Beyond direct synergistic or opposing mechanisms of action, drugs may also affect overall nutritional status in a variety of ways. These may include (but are not limited to) effects on the oral cavity (e.g., mucositis/stomatitis from antineoplastics), reduced salivary flow (e.g., anticholinergics), oral candidiasis (e.g., broad-spectrum antibiotics), taste disturbance (e.g., clarithromycin, zopiclone) or olfactory disturbance/parosmia (e.g., terbinafine, amiodarone). Overall nutritional status can also be affected by gastrointestinal effects of drugs, such as gastroesophageal reflux, gastritis and delayed gastric emptying (e.g., semaglutide), ulceration/bleeding (nonsteroidal anti-inflammatory drugs), constipation, diarrhea and dehydration (various drugs), increased appetite/weight gain (e.g., corticosteroids or second-generation antipsychotics) or decreased appetite/weight loss (e.g., stimulants for treatment of ADHD, topiramate). The impact of nutritionally active excipients (e.g., lactose, mannitol, sorbitol, aspartame, soy, vegetable oils, milk proteins, various colourants, emulsifiers and preservatives, and many others) may lead to sensitivities, interactions or adverse reactions and should be considered when evaluating DNIs. Pharmacist’s role in management of drug–nutrition interactions Pharmacists are well versed in discussing and managing drug interactions and frequently provide patient counselling information that addresses DNIs. For example, DNI counselling may include advice to take a medication one hour before or two hours after a meal with plain water; increase dietary potassium intake with use of thiazide diuretics; or avoid grapefruit juice when taking certain medications. Being attuned to the possibility that your patient may be at risk of, or actually experiencing, one or multiple DNIs is the first and often the most important management step. Pharmacists should incorporate DNI information into their patient medication counselling and during performance of medication reviews. This includes optimal medication administration instructions (and alternate formulations or methods of administration in patients with feeding tubes or swallowing difficulties); evidence-based dietary recommendations for management of the condition(s) treated by a given drug; foods and natural products to avoid; and possible nutritional adverse effects of drug treatment, along with appropriate monitoring/testing recommendations. Pharmacists may also be asked to help evaluate for the possibility of a DNI retrospectively, after an adverse effect has been discovered. Doing so requires a careful dietary and drug history, including all nutritional supplements, complementary and alternative medicines, and access to reputable resources with a focus on DNIs (Box 1). Summary Drug-nutrition interactions may arise due to alterations in pharmacokinetics, nutrient kinetics, or by alteration of therapeutic or adverse effects and nutrient action or nutritional status, with various risk factors and mechanisms identified. DNIs may lead to an increase in lab testing and medication utilization, ineffective or prolonged treatment or hospital stay, and decreased quality of life. Pharmacists can play a significant role in detecting and managing DNIs. They should work with the interdisciplinary team to plan and coordinate drug therapy along with diet and use of nutritional supplements. Dean Elbe (dniteam@drugnutritioninteractions.com) is a Clinical Pharmacy Specialist at the Healthy Minds Centre at BC Children’s Hospital, a Board-Certified Psychiatric Pharmacist, and an author and international speaker on drug–nutrition interactions and child and adolescent psychopharmacology. Dean is the author of Food–Medication Interactions 18th & 19th editions, editor of Food–Medication Interactions 13-17th editions, author of the Drug Nutrition Interactions chapter in the upcoming Nutrition Care of the Older Adult Handbook for Dietetic Professionals, 4th edition, and President and Owner of www.drugnutritioninteractions.com. You can follow him @DrDeanElbe and Drug Nutrition Interactions @DNinteractions on X. References: Santos CA, Boullata JI. An approach to evaluating drug-nutrient interactions. Pharmacotherapy 2005;25(12):1789-800. doi:10.1592/phco.2005.25.12.1789. Mason P. Important drug-nutrient interactions. Proc Nutr Soc 2010;69(4):551-7. doi:10.1017/S0029665110001576. Pronsky ZM, Crowe JP. Clinical: food-drug interactions. In: Krause’s Food & the Nutrition Care Process. Mahan LK,Escott-Stump S, Raymond JL, eds. 13th ed. Elsevier; 2012:209-28. Porter Starr KN, McDonald SR, Bales CW. Nutritional vulnerability in older adults: a continuum of concerns. Curr Nutr Rep 2015;4(2):176-84. doi: 10.1007/s13668-015-0118-6. Doan J, Zakrzewski-Jakubiak H, Roy J, et al. Prevalence and risk of potential cytochrome P450-mediated drug-drug interactions in older hospitalized patients with polypharmacy. Ann Pharmacother 2013;47(3):324-32. Canadian Institute for Health Information. Drug use among seniors in Canada, 2016. Ottawa, ON: CIHI; 2018. (accessed February 2, 2023). Niedert KC, Carlson MP, eds. Chapter 17: Implications of drug-nutrient interaction and pharmacology. Nutrition care of the older adult, 3rd Ed. Academy of Nutrition & Dietetics, 2016. Mospan CM. Drug-induced nutrient depletions: what pharmacists need to know. US Pharm 2019:44(12):18-24. Upjohn Canada ULC. Dilantin (extended phenytoin sodium capsules) product monograph. Kirkland, QC; March 31, 2022. (accessed April 25, 2023). Lindow J, Wijdicks EF. Phenytoin toxicity associated with hypoalbuminemia in critically ill patients. Chest 1994;105(2):602-4. AstraZeneca Canada Inc. Plendil (felodipine extended-release tablets) product monograph. Mississauga, ON; January 15, 2015. (accessed April 25, 2023). Organon Canada Inc. Saphris (asenapine sublingual tablets) product monograph. Kirkland, QC; April 27, 2021. (accessed April 25, 2023). Sunovion Pharmaceuticals Canada Inc. Lunesta (eszopiclone tablets) product monograph. Mississauga, ON; October 6, 2022. (accessed April 25, 2023). Sanofi-Aventis Canada Inc. Multaq (dronedarone tablets) product monograph. Laval, QC; June 30, 2020. (accessed April 25, 2023). Upjohn Canada ULC. Inspra (eplerenone tablets) product monograph. Kirkland, QC; May 11, 2020. (accessed April 25, 2023). Kappas A, Alvares AP, Anderson KE, et al. Effect of charcoal-broiled beef on antipyrine and theophylline metabolism. Clin Pharmacol Ther 1978;23(4):445-50. doi: 10.1002/cpt1978234445. Eagles SK, Gross AS, McLachlan AJ. The effects of cruciferous vegetable-enriched diets on drug metabolism: a systematic review and meta-analysis of dietary intervention trials in humans. Clin Pharmacol Ther 2020;108(2):212-27. doi: 10.1002/cpt.1811. Collomp K, Candau R, Millet G, et al. Effects of salbutamol and caffeine ingestion on exercise metabolism and performance. Int J Sports Med 2002;23(8):549-54. doi: 10.1055/s-2002-35530. Takeda Pharmaceuticals America, Inc. Prevacid/Prevacid FasTab (lansoprazole delayed release capsules/tablets) product monograph. Lexington, MA; March 16, 2023. (accessed April 25, 2023). Newberry C, Lynch K. The role of diet in the development and management of gastroesophageal reflux disease: why we feel the burn. J Thorac Dis 2019;11(Suppl 12):S1594-S1601. doi: 10.21037/jtd.2019.06.42. Paladin Labs Inc. Dexedrine (dextroamphetamine sulfate tablets)/Dexedrine Spansule (dextroamphetamine sulfate sustained-release capsules) product monograph. St-Laurent, QC; October 29, 2020. (accessed April 25, 2023). Botanical-Online. Acidifying and alkalinizing foods. (accessed April 25, 2023). Remer T, Manz F. Potential renal acid load of foods and its influence on urine pH. J Am Diet Assoc 1995;95(7):791-7. doi: 10.1016/S0002-8223(95)00219-7. Apotex Inc. Apo-Lithium Carbonate (lithium carbonate capsules) product monograph. Toronto, ON; December 5, 2013. (accessed April 25, 2023). Pendopharm (division of Pharmascience Inc.) Pdp-Isoniazid (isoniazid tablets/oral solution) product monograph. Montreal, QC; November 26, 2020. (accessed April 25, 2023). Snider DE Jr. Pyridoxine supplementation during isoniazid therapy. Tubercle 1980;61(4):191-6. doi: 10.1016/0041-3879(80)90038-0. Eli Lilly Canada Inc. Cymbalta (duloxetine delayed release capsules) product monograph. Toronto, ON; March 25, 2021. (accessed April 25, 2023). Sanofi-Aventis Canada Inc. Glucophage (metformin tablets) product monograph. Laval, QC; March 2, 2018. (accessed April 25, 2023). Aroda VR, Edelstein SL, Goldberg RB, et al. Diabetes Prevention Program Research Group. Long-term metformin use and vitamin B12 deficiency in the Diabetes Prevention Program Outcomes Study. J Clin Endocrinol Metab 2016;101(4):1754-61. doi: 10.1210/jc.2015-3754. Amgen Canada Inc. Aranesp (darbepoetin alfa) product monograph. Mississauga, ON; May 24, 2018. (accessed April 25, 2023). Amgen Canada Inc. Otezla (apremilast tablets) product monograph. Mississauga, ON; August 5, 2020. (accessed April 25, 2023). Cheplapharm Arzneimittel GmbH. Xenical (orlistat capsules) product monograph. Mesekenhagen, Germany; September 27, 2017. (accessed April 25, 2023). Novartis Pharmaceuticals Canada Inc. Tegretol/Tegretrol CR/Tegretol Suspension (carbamazepine tablets/controlled-release tablets/suspension) product monograph. Dorval, QC; May 27, 2021 (accessed April 25, 2023). Mintzer S, Boppana P, Toguri J, et al. Vitamin D levels and bone turnover in epilepsy patients taking carbamazepine or oxcarbazepine. Epilepsia 2006;47(3):510-5. Farkouh A, Baumgärtel C. Mini-review: medication safety of red yeast rice products. Int J Gen Med 2019;12:167-171. doi: 10.2147/IJGM.S202446. Upjohn Canada ULC. Zeldox (ziprasidone hydrochloride capsules) product monograph. Kirkland, QC: December 22, 2021. (accessed April 25, 2023). Sunovion Pharmaceuticals Canada Inc. Latuda (lurasidone film-coated tablets) product monograph. Mississauga, ON; March 18, 2020. (accessed April 25, 2023). Organon Canada Inc. Fosamax (alendronate tablets) product monograph. Kirkland, QC; July 16, 2021. (accessed April 25, 2023). Teva Canada Limited. ACT Ciprofloxacin (ciprofloxacin tablets) product monograph. Toronto, ON; March 23, 2022. (accessed April 25, 2023). AA Pharma Inc. Tetracycline (tetracycline capsules) product monograph. Vaughn, ON; January 28, 2019. (accessed April 25, 2023). AstraZeneca Canada Inc. Brilinta (ticagrelor tablets) product monograph. Mississauga, ON; February 16, 2023. (accessed April 25, 2023). Janssen Inc. Edurant (rilpivirine tablets) product monograph. Toronto, ON; January 20, 2023.(accessed April 25, 2023). Pharmascience Inc. Olestyr (cholestyramine resin for oral suspension) product monograph. Montreal, QC; February 9, 2022. (accessed April 25, 2023). Flockhart DA. Dietary restrictions and drug interactions with monoamine oxidase inhibitors: an update. J Clin Psychiatry 2012;73 Suppl 1:17-24. Apotex Inc. Apo-Hydrochlorothiazide (hydrochlorothiazide tablets) product monograph. Toronto, ON; October 14, 2020. (accessed April 25, 2023). Bayer Inc. Xarelto (rivaroxaban tablets/granules for oral suspension) product monograph. Mississauga, ON; December 2, 2021. (accessed April 25, 2023). National Institutes of Health. Vitamin K. Fact sheet for health professionals. (accessed March 27, 2023).

Food for thought: Uncovering the complexities of drug–nutrition interactions

Register for free access or login.

Related Topics