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Drug-Nutrient Interactions

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Suwaldi Martodihardjo

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NUTRIENT-DRUG AND DRUG-NUTRIENT INTERACTIONS
Types of Interactions
• Drug-Nutrient Interactions
– Effect of a medication on food or a nutrient in food
– Both prescription and over-the-counter
medications can affect the way the body uses
nutrients in food

• Nutrient-Drug Interactions
– Effect of food or a nutrient in food on a medication

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INTERACTIONS
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INTERACTIONS
APA YANG MENYEBABKAN ANDA
SAKIT?

• NUTRACEUTICALS: Let Food be Your Medicine


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Nutrition and Disease
• What are the consequences of poor eating habits and
lack of exercise?
▫ Obesity
▫ Osteoporosis
▫ Hypertension
▫ Stroke
▫ Diabetes
▫ Cancer
▫ Cardiovascular Diseases
▫ Long term lower quality of life
▫ Long term higher heath care
costs

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Effect of Fat Intake on Cholesterol Levels
• For individuals with relatively normal cholesterol
levels (LDL<130mg/dl), less than 10% of total daily
calories should come from saturated and trans fat

• For individuals with increased cholesterol levels


(LDL>130mg/dl), less than 7% of total daily
calories should come from saturated and trans fat

• Dietary cholesterol is not required at any level

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Cooper Institute ®
Nasib asam lemak n-3 dan n-6 dlm tubuh

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Guess what I think?
"A banana a day keeps the disease away!"

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• People depend on nutrients in their diet because the
human body is not able to produce many of these
nutrients—or it cannot produce them in adequate
amounts.

• Nutrients are essential to the human diet if they meet two


characteristics.
First, omitting the nutrient from the diet leads to a
nutritional deficiency and a decline in some aspect
of health.
Second, if the omitted nutrient is put back into the diet,
the symptoms of nutritional deficiency will decline
and the individual will return to normal, barring any
permanent damage caused by its absence.

• There are six major classes of nutrients found in food:


carbohydrates, proteins, lipids (fats and oils), vitamins
(both fat-soluble and water-soluble ), minerals , and water.
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INTERACTIONS
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INTERACTIONS
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Drugs can affect nutrient absorption in several ways

• drugs can bind to a nutrient in GIT and hinder its absorption;


this occurs with mineral oil and fat-soluble vitamins,

• drugs can speed transit time of food and nutrients and


reduce the contact time between GIT wall and the nutrients,

• drugs can change the structure or function of a nutrient so


that it becomes insoluble,

• drugs can change the acidity of GIT and impair the


absorption of nutrients,

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INTERACTIONS
Drugs can affect nutrient absorption in several
ways (cont’d)

• drugs can physically and/or chemically block absorption


sites on the GIT wall or reduce the capability of the intestinal
lining to absorb nutrients,

• drugs can absorb or interfere with the bile salts so that


dietary fat and fat-soluble vitamins are poorly absorbed,

• Drugs can interfere with the function of pancreatic digestive


enzymes.

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Nutrition Implications
• Little chance taking a medication for a short
time will affect your nutritional status

• However, using some medications for months


or years may affect one’s nutritional health
– Changing diet to include more foods rich in
vitamins and minerals is preferred to taking
vitamin or mineral supplements

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INTERACTIONS
Drug-Nutrient Interactions
• Medications, can affect nutrients by:
– Decreasing food intake
– Decreasing nutrient absorption
– Slowing down nutrient production
– Interfering with nutrient metabolism
– Increasing nutrient excretion

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INTERACTIONS
Drug-Nutrient Interactions:
Food Intake
• Some medications can affect nutritional
health by causing poor food intake due to:
– Decreased appetite
– Nausea or vomiting
– Unpleasant taste or dry mouth
– Gastrointestinal sores or inflammation

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INTERACTIONS
Drug-Nutrient Interactions:
Food Intake
• Many medications may cause loss of
appetite or nausea in some people, but it
usually subsides after the first few doses

• However, nutritional health can be affected


if decreased food intake persists

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INTERACTIONS
Drug-Nutrient Interactions:
Food Intake
• Examples:
– Appetite suppressants are medications which
affect food intake by depressing appetite
– Several cancer medications and treatments may
dramatically reduce food intake by causing:
• Loss of appetite
• Changes in taste perception
• Nausea, vomiting
• Dry mouth
• Mouth and intestinal sores or inflammation

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Drug-Nutrient Interactions:
Nutrient Absorption
• Some medications can affect nutritional
health by decreasing nutrient absorption due
to:
– Decreasing time in intestine
– Altering stomach acidity
– Damaging intestinal lining
– Competing for absorption
– Binding nutrients

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INTERACTIONS
Drug-Nutrient Interactions:
Nutrient Absorption
• Examples:
– Laxatives can cause food to move rapidly
through the intestinal track which can decrease
nutrient absorption
– Antacids can lower stomach acidity which can
may interfere with iron, folate and vitamin B12
absorption
– Many cancer medications and treatments can
damage the intestinal lining which can decrease
nutrient absorption
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INTERACTIONS
Drug-Nutrient Interactions:
Nutrient Absorption (cont.)
• Examples:
– Some anticonvulsants can compete for
absorption with folate resulting in decreased
folate absorption
– Some cholesterol lowering medications reduce
cholesterol by removing bile acids
• Bile acids are needed to absorb essential fatty acids
and fat-soluble vitamins
• As a result some cholesterol lowering medications
can reduce absorption of fat-soluble nutrients

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INTERACTIONS
INTERAKSI OBAT DENGAN NUTRISI

Interaksi obat gastrointestinal dengan nutrisi


Obat Nutrisi Efek Intervensi
Apoteker
Antasida • Besi (Fe) • Absorpsi Fe berkurang Penggunaan dipisah
paling tidak 2 jam
• Fosfat • Absorpsi fosfat
dihambat,osteomalasia
• Asam folat & • Absorpsi nutrasetika
vitamin B12 dihambat, anemia
Sulfasalazine Asam folat Absorpsi asam folat↓ Monitor terapi, jika
perlu beri tambahan
Laksansia Kalium Laksansia lama, Hindari penggunaan
hipokalemia lama
Parafin cair Vitamin larut Absorpsi vitamin A, D, E, Penggunaan parafin
lemak dan K ↓ cair lama, dihindari

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INTERACTIONS
INTERAKSI OBAT DENGAN NUTRISI
• Interaksi obat sistem kardiovaskuler dengan nutrisi

Obat Nutrisi Efek Intervensi Apoteker

Diuretika tiazid Kalsium/ Level Ca serum ↑ Penggunaan


vitamin D bersama dapat
dilakukan, monitor
pasien
ACE inhibitors Kalium Dapat timbulkan Hindari kalium
hiperkalemia berat
Diuretika Kalium Dapat timbulkan Hindari kalium,
hemat kalium hiperkalemia berat kecuali level K serum
dimonitor
Calcium Kalsium Kalsium antagonis Efek verapamil ↓,
channel dengan verapamil hati-hati
blockers penggunaan
bersama
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INTERACTIONS
INTERAKSI OBAT DENGAN NUTRISI
Interaksi obat sistem kardiovaskuler dengan nutrisi
Obat Nutrisi Efek Intervensi Apoteker
Hydralazine Vitamin B6 penggunaan Hydralazine Tmbahan vitamin B6,
lama → vitamin B6 ↓ jika dipandang perlu
Cholestyramin Vitamin larut lemak Penggunaan obat lama, Pengganaan obat lama,
e/cholestipol defisiensi vitamin A, D, E, perlu penambahan
dan K vitamin
Antikoagulan Vitamin E Vitamin E dosis besar (> Hindari penggunaan
100 unit/hari), efek vitamin E dosis besar.
warfarin↑
Vitamin K VitaminK jumlah besar, Hindari vitamin K dosis
mengurangi efek besar
warfarin
Bromelain; Chondroitin Berbagai nutrasetika ini Nutrasetika ini
Minyak ikan; Bawang dapat meningkatkan efek meningkatkan efek
putih; Ginko biloba; antikoagulan antikoagulan, sehingga
Ginseng;Ekst.biji anggur penggunaan bersama
Teh hijau; asetosal dan obat
S-adenosyl Methionine antiplatelet lain perlu
(SAMe) berhati-hati
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INTERACTIONS
INTERAKSI OBAT SUSUNAN SYARAF PUSAT DENGAN NUTRISI
Obat Nutrisi Efek Intervensi

MAO Inhibtors Brewer’s yeast Brewer’s yeast memicu Hindari brewer’s


(S.cerevisiae) krisis hipertensif yeast
Anti-epilepsi: Asam folat Anti-epilepsi memicu Penambahan folat,
• phenytoin defisiensi folat, + folat jika diperlukan
• primidine sebabkan level obat↓

phenobarbitone Vitamin B6 Dosis besar, > 10 Hindari dosis besar
• valproate mg/hari, level obat↓
• carbamazepine Vitamin D Metabolisme vitamin D Dosis koreksi,
terganggu, osteomalasia 10µg/hari
Levodopa Fe Absorpsi levodopa↓ Pisah, min 2 jam

Vitamin B6 Efek levodopa↓ atau Hindari vitamin B6;


hilang oleh vitamin B6 sarankan bersama
(>5mg/hari) carbidopa/careldopa
/beneldopa
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INTERACTIONS
INTERAKSI OBAT ANTIINFEKSI DENGAN NUTRISI
Obat Nutrisi Efek Intervensi
Tetrasiklin Fe Absorpsi keduanya↓ Pisah, min2 jam

Ca/Mg/Zn Absorpsi keduanya↓ Pisah, min 2 jam

Trimethoprim Asam folat Dapat defisiensi folat Obat lama, tambah


asam folat

Quinolones Fe/Zn Absorpsi keduanya↓ Pisah, min 2 jam

Cycloserine Asam folat Dapat defisiensi folat Monitor asam


folatnya

Isoniazid Vitamin B6 Dapat defisiensi vitamin B6 Mungkin, perlu


ditambah vitamin B6

Rifampicin Vitamin D Metabolisme vit D Monitor vitamin D


terganggu, osteomalasia pasien
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INTERACTIONS
INTERAKSI OBAT SISTEM ENDOKRIN DENGAN NUTRISI
Obat Nutrisi Efek Intervensi

Hipoglikemik Aloe vera Efek potensiasi Berhati-hati


oral dan insulin Alpha-lipoic acid penggunaan
Chromium bersama-sama

Glucosamine Menurunkan efek Pasien diabetes


hipoglikemik dan insulin berhati-hati
Estrogen (KB, Vitamin C Dosis besar vit C (1g/hari), Hindari vit C
terapi pengganti) estrogen serum↑ dosis besar

DHEA Efek potensiasi Hati-hati


(dehydroepiandro kombinasi obat
sterone)

Isoflavon Efek potensiasi isoflavon Hati-hati


Biphosphonates Kalsium Absorpsi biphosphonate↓ Pisah ~ 2 jam
Obat tiroid Iodine Tiroid sulit dikontrol Hindari Iodine
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Interaksi Minuman dengan Obat
• Interaksi grapefruit Juice dengan obat
Minuman dgn Obat Efek
nutrisinya
Grapefruit Juice Calcium channel blockers: Efek calcium channel
Amlodipine; Felodipine; blocker ditingkatkan
Nifedipine; Nimodipine;
Nisoldipine
HMG-CO inhibitors (statin): Efek statin ditingkatkan
Atorvastatin; Cervastatin
Lovastatin; Simvostatin

Sildenafil (Viagra) Efek obat ditingkatkan


Diazepam (Valium)
Buspirone (Buspar)
Saquinavir (antiviral agent)
Terfenadine

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INTERACTIONS
Grapefruit

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Drugs Affected by Grapefruit Juice
→ grapefruit juice contains bergamottin and
6′7′-dihydroxybergamottin, furanocoumarins that selectively
inhibit intestinal CYP3A4 but have little effect on hepatic 3A4

→Furanocoumarins inhibit intestinal 3A4 by three


mechanisms: competitive inhibition, irreversible inhibition,
and actual loss of 3A4 through degradation of the enzyme.

These effects can occur after a single glass of grapefruit juice


and can last for up to 3 days.

→With the exception of Seville (sour) oranges, other citrus


fruits do not appear to affect intestinal CYP3A4.

05/12/2017 Drug Interx 34


Drugs Affected by Grapefruit Juice

➢grapefruit juice and 6′7′-dihydroxybergamottin significantly


reduced intestinal absorption of the OATP substrate fexofenadine.

Orange juice and apple juice were found to have similar effects

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Drugs Affected by Grapefruit Juice

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Drugs Affected by Grapefruit Juice

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Drugs Affected by Grapefruit Juice

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Drugs Affected by Grapefruit Juice

05/12/2017 Drug Interx 39


GIVE ME A LITTLE BREAK,
PLEASE !

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The 7 (Seven) Habits of Highly Effective People
• Covey (1989) writes that the behaviors of effective people are
powerful lessons that others can use to motivate personal
change.

The Seven Habits:


1. Be proactive.
• Use the four fundamental human endowments (self-awareness,
imagination, conscience, and independent will) to choose your
behavior.
• Realize that behavior is a function of decisions not conditions.

• Thus, practicing a pharmaceutical care should be made as a


matter of choice not an edict from a professional guru or group.
• The pharmacists should focus on areas they control rather than
on blaming others and understand that they control their destiny.
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2. Begin with the end in mind. .

▪ (This is often called the Habit of Personal Leadership)


• .

▪All things are created twice, first in the mind and then
in reality, and success comes from having a clear plan
of what you want to achieve.

▪For pharmacists, they should have the ability to


envision pharmaceutical care and place it in context
with their ethical values and guidelines is paramount in
achieving success.

▪The pharmacists can decide what they want to


accomplish in their lives and should realize that all
accomplishments must begin in their own minds.
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3. Put first things first. .


▪ This
is the exercise of free will that makes effective
.

self-management possible.
▪The pharmacists learn how to achieve their “vision”
or personal mission through effective organization
and implementation based on their previously
determined priorities.
▪It applies to those who are disciplined, act with
strength of purpose, and organize and execute around
priorities.
▪Thus, pharmaceutical care will not be mainstreamed
until pharmacists make a personal effort at setting it
as a professional and personal priority.
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4. Think win-win.
.

▪ Pharmacists learn how to negotiate win-win


agreements with an outcome beneficial to both
• .
parties- necessary to achieve long-term, positive
relationships.
▪ This is also called “Root of Interdependence”.
▪ Thus for pharmaceutical care to work, it must be
applied with fairness to all patients.

5. Seek first to understand, then to be understood.


▪ Communication is an essential skill for everyone to
be effective and successful in life, and without this
ability any pharmacist dedicated to pharmaceutical
care will find success a difficult pathway.
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6. Synergize. .

▪ Synergy is the essence of principle-centered leadership.


Synergize needs:
• .

• the four unique human endowments (self-awareness,


imagination, conscience, and independent will),
• the skills of empathetic communication, and
• The motivation behind a win-win attitude so that
relationships can be built to produce an outcome greater
than its parts.
• The pharmacist who wants to provide a pharmaceutical
care practice in an advanced level must first build a level
of creative cooperation so patients see this new
environment of care fulfilling to both.
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.
7. Renewal or Sharpen the saw

▪ In this habit, pharmacist needs to preserve, enhance,


• .

and renew the four dimensions of his/her nature


(physical, mental, social/emotional, and spiritual) in a
wise and balanced way so that he/she can preserve
and enhance his/her ability to do work.

▪Pharmacists who miss out on this balancing act as a


long-term way of life will not have what it takes to make
an effective commitment to a new paradigm of care.

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2017
DRUG EFFECTS ON NUTRIENTS

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2017
Overview
Of almost 900 drugs and fixed-drug
combinations used in the U.S.:
• Almost 400 may deplete specific nutrients.
• Over 400 may interact with food or food
components.
• Over 300 have been shown to interact with
dietary supplements, with adverse and
beneficial interactions equally common.

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Effects of Interactions
• Nutrient depletion: Individual nutrients may have their
dietary requirement increased by specific drugs (or
supplements).

• Adverse: A specific supplement may undesirably


decrease or increase the effect of a drug or supplement
being taken.

• Beneficial: Drugs (or supplements) may have their


actions enhanced or side effects diminished by specific
supplements.

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Drug-Induced Nutrient Depletion
• About half the drugs used in clinical practice
have documented nutrient depleting effects.

• Co-enzyme Q10, folic acid, B2, B6, Mg, Zn


are nutrients most likely to be depleted.

• Mechanisms include impaired absorption or


bioactivation or increased excretion.

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Co-enzyme Q10 Depletion
• Statin-induced co-Q depletion impairs
mitochondrial function, raising the serum
lactate/pyruvate ratio.
• Simvastatin but not atorvastatin depletes
myofibrillar co-Q.

• Supplemental co-Q, 100 mg/day, prevents the


decline in serum co-Q levels without impairment of
the lipid-lowering effect of statins and may reverse
symptoms of statin myopathy.
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2017
Co-enzyme Q10 Depletion (cont’d)
• Statin-induced Co-Q depletion is increased by
vitamin E (700 IU/day).
• Co-Q is consumed in recycling tocopheryl-quinones
back to tocopherols.
• Thiazides, some beta-blockers and many older
psychotropic drugs have been shown to interfere
with co-Q dependent enzymes, creating a possible
need for co-Q supplementation in patients receiving
them.

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Clinically Significant Depletions-1
• Adriamycin depletes co-enzyme Q10.
Cardiotoxicity is reduced by co-Q10 and
proprionyl-L-carnitine.

• Cisplatin depletes Mg.


Nephtrotoxicity is reduced by i.v. and oral Mg (160
mg tid).

• Thiazides and 5-ASA derivatives deplete folate,


raising homocysteine concentration → may cause
atherosclerosis

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Clinically Significant Depletions-2
• Loop diuretics increase excretion of K, Ca,
Mg, Zn, vit B1, B6, and C.
Correcting B1 deficit improves cardiac
function of CHF patients.
• Cephalosporins (parenteral) can deplete
vitamin K, causing hemorrhage.
• Steroids deplete Ca and Mg, causing bone
loss. Reversible with calcium and vitamin D3.
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Antiretroviral Nutrient Depletion
• AZT depletes muscle carnitine and increases
lymphocyte apoptosis.
Reversed with carnitine supplementation.
• AZT is associated with decreased serum zinc
and copper;
• Zinc 200 mg/day reduced Candida and
Pneumocystis infections in patients taking
AZT.

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Phenytoin-induced Depletions
• Phenytoin may deplete biotin, folate,
thiamine, vitamin D (causing hypocalcemia
and osteomalacia and vitamin K.

• Memory impairment is associated with


reduced RBC folate.
Folic acid, 1 mg/day, prevents deficiency
without adversely affecting phenytoin
metabolism.
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Valproic Acid Depletions
• Valproate depletes carnitine, raising
ammonia; reversed with carnitine 2 g/day.
• Valproate acid lowers serum folate and P5P,
raising homocysteine; reversed with 400 mcg
of folate, 120 mg of B6 and 75 mg of B2.
• Valproate inhibits biotinidase. Biotin of 10
mg/day reverses valproate-associated hair
loss and dermatitis in children.
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INTERACTIONS
Deplesi Nutrisi Karena Obat NSAID
Deplesi Besi •Kerusakan DNA oksidatif Dosis koreksi
•Anemia dan imunitas turun - 100-200 mg/ hari
•Disfungsi kognitif (anak) - 2-3mg/kg/hari

Deplesi Melatonin • terganggu siklus bangun-tidur Dosis 0,3 -5 mg

Deplesi Asam Folat • Kanker kolon RDA 300 – 600 µg/hari


• Penyakit jantung
•Defisit kognitif Dosis dapat sampai 2000
•Neural tube defects µg/hari
• Kerusakan kromosom
•Anemia megaloblastik
Deplesi Zinc • Alopesia; dermatitis; diare; Dosis sampai 50 mg/hari
hambatan pertumbuhan;
imunitas turun;
selera makan turun/hilang

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INTERACTIONS
Deplesi Nutrisi Karena Obat Turunan Penisilin
Deplesi Probiotika • Menurunkan daya tahan Pemberian L. acidophilus
• Gejala: - timbul gas ; diare dan L bulgaricus atau S.
boulardii dengan dosis
- perut tidak enak
3xE10 CFU ( 1g/hari)
- infeksi jamur
Deplesi vitamin B2 • Mempengaruhi metabolisme karbohidrat Terapi koreksi, dosis 5
(umumnya bersama dan asam amino – 25 mg/hari;
dengan vitamin B •Gejala: vaskularisasi kornea, glossitis,
lain) cheilosis, seborrheic, dermatitis, luka sulit
sembuh
Deplesi Asam Folat Seperti pada NSAID Seperti pada NSAID
Deplesi vitamin B12 Meningkatkan resiko kanker kolon, penyakit Dosis koreksi:
jantung, disfungsi otak, dan neuropati 25 -250 µg/hari; untuk
irreversible. anemia,
Gejala: lemah, letih, lesu, iritabilitas, 500-1000µg/hari
anoreksia, sakit kepala, glossitis, palpitasi, dan
perubahan status mental
Deplesi Biotin Gejala non-spesifik: alopesia, nyeri otot, Dosis koreksi:
(vitamin H) dermatitis, perubahan warna kulit, anemia, 1-10 mg/hari
anoreksia, depresi, insomnia, hiperkolesterol
Deplesi vitamin K
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Terjadi gangguan koagulasi,
NUTRIENT-DRUG akibatnya
AND DRUG-NUTRIENT Dosis koreksi: 59
pendarahan INTERACTIONS 45 -80 µg/hari
Deplesi Nutrisi Karena Obat Antidiabetik
Obat Deplesi Signifikansi Dosis Koreksi
Nutrisi
Turunan Asam Folat Seperti pada NSAID Seperti pada
Biguanida: (vitamin B9) NSAID
Metformin
Cobalamin Seperti pada obat turunan penisilin Seperti pada obat
(vitamin B12) turunan penisilin

Turunan Coenzyme Q10 -Penuaan/aging dan photoaging 2 x sehari 100 mg;


Sufonylurea: (CoQ10), -Fungsi imun berkurang Dosis ini
Glyburide, hambatan -Infertilitas pria ditoleransi
Glimepiride pada Berkurangnya CoQ10 diasosiasikan dengan baik dan
NADH-oxidase dengan berbagai penyakit, seperti: tidak
gingivitis, kanker payudara, gagal mempengaruhi
jantung kongestif, angina pektoris, pengontrolan
infark myocardial akut, hipertensi, gula darah
fungsi jantung tidak normal, dan
mitochondrial
encephalomyo-pathies
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NUTRIENT-DRUG AND DRUG -NUTRIENT INTERACTIONS
Deplesi Nutrisi Karena Diuretika Turunan Tiazid
Deplesi Nutrisi Signifikansi Dosis Koreksi
Natrium dan • Deplesi Na tidak umum terjadi; The US dietary
klorida • Defisiensi Na menimbulkan mual, sakit kepala, guideline:
lemah, bingung, stupor, kejang, dapat sampai koma. 2,4 g/hari atau
• Problema klinis lebih banyak terjadi pada usila. NaCl = 6 g/hari
Coenzyme Q10 • Seperti pada sulfonylurea; Seperti pada
• Penggunaan kombinasi diuretik tiazid dengan sulfonylurea
pemblok beta-adrenergik → potensi deplesi
meningkat
Magnesium • Deplesi Mg berat → hipokalsemia Kebutuhan harian
• Hipomagnesemia (≤ 17 mg/L) Mg =
→ hipereksitabilitas neuromuskular 30-420mg/hari
→ penyakit kardiovaskular, hipertensi, diabetes,
dan osteoporosis
Kalium Tanda dan gejala: anoreksia, merasa takut, Koreksi defisiensi:
mengantuk, lelah, mual, kram dan otot lemah, tetani, 20-100 mEq/hari
sangat haus, tidak ingin melakukan sesuatu, status Alkalosis → KCl
mental berubah Asidosis→ Garam
Hipokalemia berat → aritmia jantung, jantung bikarbonat, sitrat,
berhenti, dan kematian asetat, glukonat
Zinc Seperti pada NSAID; kombinasi tiazid & ACEI → Sampai 50mg/hari
Selasa, 05 Desember 2017
deplesi lebih NUTRIENT-DRUG
cepat, monitorANDlevel Zn
DRUG-NUTRIENT
61
INTERACTIONS
Deplesi Nutrisi Karena Diuretika Loop
Deplesi Nutrisi Signifikansi Dosis Koreksi

Kalsium (Ca) •Deplesi Ca belum konklusif. 1000 – 1500 mg/hari,


Penelitian masih perlu dilakukan. sebagai garam sitrat,
•Bila terjadi deplesi Ca, tanda dan malat, glukonat, atau
gejala meliputi aritmia, iritabilitas karbonat
neuromuskular, dan perubahan
status mental
Magnesium (Mg) Seperti pada diuretika tiazid Seperti pada diuretika
tiazid
Fosfat (PO4) Deplesi fosfat jarang dijumpai. Rekomendasi:
Asupan suboptimal timbulkan 100 -1250mg/hari
deplesi; gejala deplesi →
kelemahan fisik umum
Kalium (K) Seperti pada diuretika tiazid Seperti pada diuretika
tiazid

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INTERACTIONS
Deplesi Nutrisi Karena Diuretika Loop (lanjt)
Deplesi Nutrisi Signifikansi Dosis Koreksi
Vitamin B1 •Penggunaan IV (6 jam), kehilangan vit B1 RDA: 1,1 – 1,5 mg/hari
signifikan. Pengatasan deplesi lanjut,
•Manifestasi deplesi awal: lemah, lelah, terjadi beri-beri, dosis oral
anoreksia, konstipasi, nistagmus, dan 5-10mg/hari (1 bulan)
perubahan status mental.
•Umumnya, deplesi terjadi bersama-sama
dengan deplesi vitamin B lainnya
Vitamin B6 Tanda dan gejala deplesi antara lain Defisiensi diet:
dermatitis, anemia, lemah, bingung, 10-20mg/hari;
iritabilitas, nerves, insomnia, dapat terjadi neuropatologi diberi dosis
konvulsi epileptiform dengan EEG abnormal. 50-200mg/hari
Deplesi vit B6 meningkatkan resiko kanker
kolon dan prostat, penyakit jantung, dan
disfungsi otak.
Vitamin C Deplesi dapat timbulkan meriang, lelah, suhu Scurvy: 300-1000mg/hari
naik, anemia, icterus, edema, hipotensi, Rekomendasi lain:
gangguan gusi, gigi lepas, perubahan 60-2000mg/hari
emosional, luka sulit sembuh, mudah kena Penggunaan sebaiknya
infeksi, sintesis kolagen defektif, dll. tidak lebih dari
Defisiensi vit C dapat tingkatkan resiko 1000mg/hari karena dapat
katarak dan penyakit jantung.
NUTRIENT-DRUG AND DRUG-NUTRIENT sebabkan mual dan diare
Selasa, 05 Desember 2017 63
INTERACTIONS
MANFAAT KOMBINASI OBAT-NUTRISI
Nutrasetika (Nutrisi) Obat/Nutrisi lain Kegunaan

Hydroxycitrate/carnitine Metformin Reduksi lemak tubuh


Fish oil Magnesium taurate Mencegah migraine
Epicatechin gallate Oxacillin/ß-laktam lain Efek antibakteri ↑
Theanine Doxorubicin Aktivitas antitumor ↑
Catechin teh hijau Amphotericin B Aktivitas antifungi ↑
Coenzyme Q10 Fenofibrate Memperbaiki
mikrosirkulatori pada
diabetes
Coenzyme Q10 Enalapril/nitrendipine Efek hipotensif ↑
Policosanol Cimetidine Perbaikan tukak gastrik ↑
Asam lipoat Asam Antioksidan ↑
askorbat/tocopherol
Kedelai Oats Diet penurun lemak
Carnitine Simvastatin Penurun lipid
Carnitine NUTRIENT-DRUG AND DRUG-NUTRIENTPrevensi thrombosis
Prostacycline
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INTERACTIONS
MANFAAT KOMBINASI OBAT-NUTRISI
Nutrasetika (Nutrisi) Obat/Nutrasetika (Nutrisi) Kegunaan
lain
Piperine Isoniazid/rifampicin Antibakteri TBC dan Lepra ↑

Carnitine Propionate Oksidasi asam lemak di liver


Melatonin Vitamin D3 Inhibisi sel kanker payudara↑

Melatonin Chalcones Cytoprotective ↑


Melatonin Tamoxifen Cytotoxic ↑
Melatonin Meloxicam Proteksi stroke ischaemic
Melatonin Diazepam Aktivitas anxiolytic ↑
Asam lipoat Acetyl-L-carnitine Penyakit Alzheimer
Creatine Hydroxymethylbutyrate Massa otot dan tubuh tanpa
lemak ↑

DHA/EPA Ibuprofen/ketoprofen Penetrasi topikal NSAID↑


GLA (γ-linolenic acid)
Selasa, 05 Desember 2017
Tamoxifen
NUTRIENT-DRUG AND DRUG-NUTRIENT Penetrasi topikal tamoxifen↑
65
INTERACTIONS
The Cytochrome P450 System and
Drug-Supplement Interactions
• Expressed chiefly in liver, intestines, lungs
and kidneys (“Phase 1 detoxication”).
• 20 different human CYPs, grouped by amino
acid homology, not by function.
• CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP2E1
and CYP3A4 most important for oxidation of
drugs, xenobiotics.

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INTERACTIONS
CYP1A2
• Liver only.
• Inactivates caffeine and bioactivates
aromatic and heterocyclic amines;
• large inter-individual differences (up to
100-fold).
• Induced by char-broiled meat, cigarettes,
pollutants, dioxins and cruciferous
vegetables.

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INTERACTIONS
CYP2: Drug-Drug Interactions
• CYP2C9 accounts for 30% of CYP activity in human
liver. May be modified by Ginkgo biloba.
• CYP2C19 is primarily hepatic. Phenotype reflects
the interaction of 8 gene alleles.
• CYP2D6 is extra-hepatic.
Bioactivates codeine/codones. 55 alleles.
• CYP2E1 in liver, lung, brain metabolizes organic
solvents like ethanol.
• Induced with chronic ethanol use, fasting, obesity.
Inhibited by acute alcohol intake, tea, broccoli,
garlic, onion, watercress.
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INTERACTIONS
CYP3A4
• Liver and small intestine.
• Transforms about 50% of common drugs.
• Induced by St. John’s wort (liver, intestine)
and Echinacea (liver only).
• Inhibited by peppermint oil and piperine.
• Intestinal but not liver CYP3A4 is inhibited by
grapefruit juice, Seville orange juice and
Echinacea.
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INTERACTIONS
Cytochrome P450 3A
• Responsible for metabolism of:
– Most calcium channel blockers
– Most benzodiazepines
– Most HIV protease inhibitors
– Most HMG-CoA-reductase inhibitors
– Most non-sedating antihistamines
– Cyclosporine
• Present in GI tract and liver

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INTERACTIONS
CYP3A Inhibitors
• Ketoconazole
• Itraconazole
• Fluconazole
• Cimetidine
• Clarithromycin
NOT Azithromycin
• Erythromycin
• Troleandomycin
• Grapefruit juice
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71
INTERACTIONS
CYP3A Inducers
• Carbamazepine
• Rifampin
• Rifabutin
• Ritonavir
• St. John’s Wort

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INTERACTIONS
CYP3A4 and St. John’s Wort
CYP3A4 stimulation by St. John’s wort reduces:
• blood levels of benzodiazepines,
• calcium channel blockers,
• anti-retrovirals,
• estrogens (including OCPs), amitriptyline,
cyclosporine, methadone, tacrolimus, and
• possibly warfarin.

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INTERACTIONS
Intestinal CYP3A4 Inhibition
• Increases blood levels of amiodarone,
artemisinin, atorvastatin, buspirone,
carbemazepine, cyclosporine, diazepam,
diltiazem, erythromycin, estradiol,
felodipine, fentanyl, fluoxetine, lovastatin,
methyl-prednisolone, nifedipine, nimodipine,
praziquantel, saquinavir, sertraline,
sildenafil, simvastatin, verapamil

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INTERACTIONS
P-glycoprotein Transporter (P-gp)
• Ejects xenobiotics from cells and causes
backflow of some drugs from intestinal
mucosa into the lumen.
• Produces multi-drug resistance to cancer
chemotherapy.
• Inhibited by piperine, milk thistle and acutely
by St. John’s wort.
• Stimulated by continued St. John’s wort.

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INTERACTIONS
Drug Transporters
• P-Glycoprotein and others
• Pump drugs out of cells, which alters
distribution
• Found in the following tissues:
– Gut
– Gonads
– Kidneys
– Biliary system
– Brain (blood-brain barrier)
– Placenta

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INTERACTIONS
P - Glycoprotein Tissue Distribution

NUTRIENT-DRUG
Marchietti S, et al. Clinical relevance AND DRUG-NUTRIENT
of drug-drug and herb-drug interactions mediated by the
Selasa, 05 Desember 2017 77
INTERACTIONS
ABC transporter ABCB1 (MDR1, P-glycoprotein). The Oncologist 2007;12:927-41.
P-Glycoprotein (PGP) Substrates

Bauer B, Hartz AM, Fricker G, Miller D. Modulation


NUTRIENT-DRUG of p-Glycoprotein Transport Function at the
AND DRUG-NUTRIENT
Selasa, 05 Desember 2017 Blood-Brain Barrier. Experimental Biology and Medicine Feb. 2005;230:118-27. 78
INTERACTIONS
Digoxin and PgP
• Digoxin is a PgP substrate
• Increased digoxin plasma conc.
when DIGOXIN is combined with:
Quinidine Verapamil
Talinolol Clarithromycin
Erythromycin Itraconazole
Ritonavir
NUTRIENT-DRUG AND DRUG-NUTRIENT
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INTERACTIONS
Both PGP and CYP3A4
• Inhibitors • Inducers
– Verapamil – Rifampicin
– Clarithromycin – St. John’s Wort
– Erythromycin – Phenobarbital
– Itraconazole – Reserpine
– Ritonavir
– Cyclosporine
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INTERACTIONS
Alteration of Intestinal CYP3A4 and/or
P-glycoprotein
• Often involves the same substrates.

• Primarily effects drugs that pass slowly


through intestinal mucosa.

• Interactions in vivo may not be predicted by


interactions in vitro.

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INTERACTIONS
Beneficial Drug-Supplement Interactions

• Reflect additive/complementary effects of


supplements and drugs, or amelioration of
toxic drug effects by supplements.

• Fish oils enhance anti-inflammatory,


antiarrhythmic, anti-lipemic, antidepressant,
and neuroleptic drugs, beta-blockers, lithium
and insulin.
• EPA and DHA may have differential effects.
NUTRIENT-DRUG AND DRUG-NUTRIENT
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INTERACTIONS
Acetaminophen Toxicity
• Protective supplements:
N-acetyl cysteine (clinical use)
L-methionine and SAMe
Milk thistle
Andrographis
Schisandra

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INTERACTIONS
ASA/NSAID Gastropathy
• Protective supplements (human trials):
Vit C (500-1000 mg bid)
SAMe 500 mg/day
Cayenne 20 grams
Deglycyrrhizinated licorice 350 mg tid
Colostrum 125 mg tid

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INTERACTIONS
Neuroleptic Side Effects
• Protective supplements:
Vitamin E 1200-1600 IU/day (T.D.)
Branched chain amino acids (T.D.)
Ginkgo biloba 350 mg/day
Sarcosine (N-CH3-glycine) 2 gm/day
Eicosapentaenoate (EPA) 2 gm/day
Glycine 0.4-0.8 mg/kg/day

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INTERACTIONS
Cisplatin Toxicity
• Protective supplements:
Bismuth 150 mg/kg/day X 10days
Ginkgo bilomba 100 mg/kg single dose
Glutathione 5 gm i.v.
MgSO4 3 gm i.v./ Mg 160 mg tid
Silibinin 200 mg/kg i.v. single dose
N-acetyl cysteine 8 gm/day
Selenium 4000 mcg/day X 8 days
Vitamin C 50-200 mg/kg i.v. single dose
Vitamin E 300 IU/day till 3 months post-chemotherapy

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INTERACTIONS
More Antineoplastic Toxicity
• Protective supplements
Vitamin B6 50 mg tid
Glutamine 30 gm/day
Melatonin 20 mg HS
Coriolus versicolor 1 gm tid
Theanine (in vitro)
Inositol hexaphosphate (IP6) (in vitro)
Calcium D-glucarate (in vitro)

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INTERACTIONS
Drug-Nutrient Interactions:
Nutrient Production
• Some medications can affect nutritional
health by slowing down nutrient production

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INTERACTIONS
Drug-Nutrient Interactions:
Nutrient Production
• Vitamin K produced by bacteria in the
intestine

• Antibiotics kill harmful bacteria, but they can


also kill helpful bacteria
– Killing helpful vitamin K producing bacteria can
result in decreased vitamin K production

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INTERACTIONS
Drug-Nutrient Interactions:
Nutrient Metabolism
• Some medications can affect nutritional
health by interfering with body’s ability to
metabolize nutrients due to:
– Affecting enzyme systems
– Competing with enzyme systems

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INTERACTIONS
Drug-Nutrient Interactions:
Nutrient Metabolism
• Examples:
– Some anticonvulsants alter liver enzyme activity
causing increased metabolism of folate, vitamin
D, and vitamin K

– Methotrexate resembles folate in structure and


competes with enzymes that converts folate to its
active form, this can result in folate deficiency

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INTERACTIONS
Drug-Nutrient Interactions:
Nutrient Excretion
• Some medications can affect nutritional
health by increasing nutrient excretion due
to:
– Decreased kidney reabsorption
– Increased urinary excretion

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INTERACTIONS
Drug-Nutrient Interactions:
Nutrient Excretion
• Diuretics remove excess fluid from the body
– Some diuretics may also increase loss of
potassium along with fluids
– Potassium is very important in proper functioning
of the heart and other muscles

• Large amounts of aspirin can cause increased


loss of folate

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INTERACTIONS
Drug-Nutrient Interactions:
Nutrient Excretion
• Examples:
– Some anticonvulsant medications can cause the
liver to increase removal of vitamin D from the
body

– Isoniazid, an antituberculosis medication, is


similar in structure to vitamin B6 and induces
vitamin B6 excretion
• Since treatment is for 6 months, B6 supplements are
routinely given to prevent deficiency
NUTRIENT-DRUG AND DRUG-NUTRIENT
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INTERACTIONS
Food-Drug Interactions
• Some foods or nutrients in food can also alter
a medication’s effectiveness by:
– Decreasing medication absorption
– Interfering with medication metabolism
– Interfering with medication removal

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INTERACTIONS
Nutrient Interactions:
Medication Absorption
• Some foods or nutrients in food can increase or
decrease medication absorption by:
– Decreasing stomach emptying
– Binding to medications
– Competing for absorption
– Altering acidity

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INTERACTIONS
Nutrient Interactions:
Medication Absorption
• Absorbing less than the intended dose lowers
the chance a medication will work properly

• Absorbing more than the intended dose


increases the chance of an overdose effect

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INTERACTIONS
Nutrient Interactions:
Medication Absorption
• Medications are typically absorbed more
quickly when the stomach is empty

• Having food in the stomach typically will slow


down a medications absorption

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INTERACTIONS
Nutrient Interactions:
Medication Absorption
• Some medication should be taken with food
• Some medication should be taken on an
empty stomach (1 hour before or 2 hours
after eating)
• Read the directions to see if a medication
should or should not be taken with food

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INTERACTIONS
Nutrient Interactions:
Medication Absorption
• Examples:
– Dietary calcium can bind to the antibiotic
tetracycline making it unavailable for absorption

– Amino acids compete for absorption with


levodopa

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INTERACTIONS
Nutrient Interactions:
Medication Absorption
• Examples:
– Acidity of food or beverage consumed with a
medication can affect absorption
• Some medications are better absorbed in an acidic
environment
• Other medications can be damaged by an acid
environment, these types of medications are often
available in coated forms to resist stomach acidity

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INTERACTIONS
Food-Drug Interactions:
Medication Metabolism
• Some foods or nutrients in foods may
interfere with a medication’s metabolism or
action in the body by:
– Affecting enzyme systems
– Interacting with medications
– Having a similar chemical structure resulting in
competition

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INTERACTIONS
Food-Drug Interactions:
Medication Metabolism
• Examples:
– Components in grapefruit juice
• Inactivate enzymes that metabolize many medications
which can result in increased medication levels
– Aged and fermented foods
• Contain a chemical called tyramine that interacts with a
medication, monoamine oxidase inhibitor, which can
result in dangerously high blood pressure
– Vitamin K
• Structurally similar to the anticoagulant warfarin which
can decrease the effectiveness of warfarin
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INTERACTIONS
Food-Drug Interactions:
Medication Removal
• Some food or nutrients in foods may interfere
with removal of a medication from the body
by:
– Affecting enzymes involved in preparing
medications for removal
– Altering urine pH

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INTERACTIONS
Food-Drug Interactions:
Medication Removal
• Examples
– Liver enzymes prepare medications for removal
from the body
• These enzymes require nutrients to work properly
• If nutrients are not present the medication may stay
active in the body longer than intended
– Quinidine is excreted more readily in an acidic
urine
• Foods that cause the urine to be more basic, such as
sodium bicarbonate, may reduce quinidine excretion

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INTERACTIONS
Many Medications
• These are just a few examples to understand
how medications and nutrients can interact,
this is not indented to be a complete list of
possible interactions

• There are thousands of medications on the


market and numerous new medications that
come out ever year

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INTERACTIONS
Alcohol Interacts With Medications
• Alcohol and medications do not mix
• Alcohol can adversely affect medications
– Alcohol can slow down or speed up how the body
metabolizes a medication
• Medication action can be either intensified or reduced

– In some cases, mixing alcohol and medications


can be fatal

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INTERACTIONS
Alcohol Interacts With Medications
• A rule of thumb is to avoid alcoholic
beverages when taking prescription and
over-the-counter medications

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INTERACTIONS
Nutrient Supplements
• Nutrient supplements themselves can result
in drug-nutrient interactions
• In excessive amounts, vitamin and mineral
supplements can act like drugs instead of
nutrients
• Nutrients in excessive amounts may:
– Compete with other nutrients for absorption,
transport or metabolism
– Have a direct overdose effect
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INTERACTIONS
Follow Directions
• It is very important to follow the directions
on how to take a medication
• Many people do not take prescription or
over-the-counter medications properly
• Following directions on how to take a
medication can affect how or if a medication
will work properly

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INTERACTIONS
Who Is At Greater Risk
• Persons who are poorly nourished
• Persons with serious health problems
• Growing children
• Pregnant women
• Older adults

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INTERACTIONS
Who Is At Greater Risk (cont.)
• Persons taking two or more medications at
the same time
• Persons using prescription and
over-the-counter medications together
• Persons not following medication directions
• Persons taking medications for long periods
of time
• Persons who drink alcohol excessively

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INTERACTIONS
Lower The Risk of
Drug-Nutrient Interactions
• Eat a healthy diet
• Follow directions on how to take medications
– Both prescription and over-the-counter
• Read warning labels
• Do not share medications

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INTERACTIONS
Lower The Risk of
Drug-Nutrient Interactions (cont.)
• Tell your physician all the medications you
are taking both prescription and
over-the-counter
• Tell your physician and pharmacist about
any new symptoms that develop when
taking a medication
• Keep a list of all medications
• Ask if you have any questions

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INTERACTIONS
WHAT DOES
PHARMACIST HAVE TO
DO ..IF

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INTERACTIONS
LOSS OF APPETITE
If a medication causes a temporary loss of appetite, the
following suggestions might improve food intake:
• Eat with friends or family whenever possible.
• Make food appetizing. Choose a variety of colors, textures,
and aromas and serve food attractively.
• Create a pleasant atmosphere at the dining table. Use soft
lights, quiet music, and brightly colored table accessories.
• Sip on fluids that provide calories (juices, milk-shakes, milk, or
nectars).
• Have snacks by the bed at night (nuts, dried fruits, or candy).
NUTRIENT-DRUG AND DRUG-NUTRIENT
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INTERACTIONS
LOSS OF APPETITE (Cont’d)
• .
•Place snacks throughout the house or keep non-sugary
foods readily available, such as fresh or dried fruits,
vegetables, or cottage cheese.
•Schedule small quantities of food to eat, i.e., two bites
every hour or eat small meals frequently throughout the
day.
•Eat when hungry, regardless of time.
•Exercise about one-half hour prior to a meal.
•Vary the diet and try new recipes.
•Use days, when eating, is enjoyable to catch up on
nutrition.
•Take a multiple vitamin-mineral
Selasa, 05 Desember 2017
INTERACTIONS
supplement.
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117
NAUSEA
If a drug produces temporary nausea, try the following:
• Eat small meals frequently throughout the day.

• Avoid liquids at mealtime. Drink fluids one hour before or


after meals.

• Avoid sweets and fried or fatty foods.

• Eat slowly

• Chew food well.

• Eat dry foods, such as toast and crackers. These foods ease
upset stomach, especially in the morning.
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INTERACTIONS
NAUSEA (Cont’d)
If a drug produces temporary nausea, try the following:

• Drink cold, clear liquids, such as apple juice, cranberry juice, or


broth.

• Eat light meals, such as soup and crackers, before treatment,


unless nausea results from radiation. In this case, refrain from
eating for several hours prior to treatment.

• Avoid kitchen if the smell of food produces nausea or vomiting.

• Do not lie down for at least two hours following a meal. Resting
in a comfortable chair, however, is helpful for digestion.

• Take deep breaths or find other distractions to relieve nausea.

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INTERACTIONS
DIARRHEA
If a drug causes temporary diarrhea, try the following:
• Eat foods warm rather than hot. Higher temperatures
increase transit time of foods in the intestines, making
bowels looser.
• Avoid gas-producing foods, such as beans, cabbage,
broccoli, cauliflower, chewing gum, soda, highly spiced
foods, and too many sweets. Avoid caffeine-containing
foods such as coffee, tea, cola, and chocolate.
• Include potassium rich-foods, such as bananas, potatoes,
or apricot or peach nectar in the diet.
• Dairy products aggravate diarrhea and might need to be
avoided temporarily.
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INTERACTIONS
DIARRHEA (Cont’d)
If a drug causes temporary diarrhea, try the following:

• Do not skip meals if possible

• Eat low fiber foods, such as bananas, macaroni, and cheese.

• Avoid high fiber foods, such as whole grain, breads and


cereals, raw fruits and vegetables, popcorn, and nuts.

• Eat food that contain pectin, such as applesauce or grated


apples.

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INTERACTIONS
TASTE CHANGES
If a drug alters the taste of food or causes it to be bitter or
tasteless try the following:
• Try highly seasoned and flavored foods.

• Avoid beef or pork, since these meats are the most likely to
cause taste aversions.

• Prepare foods that look and smell appetizing.

• Try chicken, turkey, fish, eggs, and dairy products if red meat
is not appealing. Avoid strong smelling fish.

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TASTE CHANGES (Cont’d)
If a drug alters the taste of food or causes it to be bitter or
tasteless try the following:
• Acceptable foods might include: bland cheeses, cottage
cheese, fresh fruits, gelatins, salads, ice cream, lettuce, or
peanut butter.
• Pleasant smells might help, i.e., freshly baked bread or
simmering soup.
• Brush the teeth before eating.
• Rely on other senses to provide a pleasurable atmosphere.
Decorate the room and table, eat foods that provide a
variety of colors and textures, include flowers on the table.

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FULLNESS AND BLOATING
Bloat: a swelling or filling with gas, as when the stomach is
distended from swallowing air or from intestinal gas.

If a drug causes a feeling of fullness or bloating try the


following:
• Take meals without fluids. Drink fluids between meals.

• Avoid gas-forming foods, such as cabbage, dried beans, and


peas, or raisins.

• Eat and drink slowly.

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FULLNESS AND BLOATING (Cont’d)

If a drug causes a feeling of fullness or bloating try the


following:
• Choose foods that leave the stomach the stomach quickly,
i.e., breads, cereals, fruits, juices, and vegetables.

• Avoid fatty foods.

• Eat small amounts of food at frequent intervals.

• When feeling full, stop eating for a short time.

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HEARTBURN
If a drug causes temporary heartburn, try the following:

• Eat small quantities of food at frequent intervals.

• Do not homogenize, mince, or puree foods.

• Limit the use of alcohol, coffee, tea, and other


caffeine-containing beverages.

• Avoid spicy, greasy, fried, or fatty foods.

• Avoid eating before bedtime.

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COENZYME Q10

• CoQ10 merupakan kofaktor enzim yang dapat ditemukan dalam


mitokondria sel.

Coenzyme Q10

• Berpenanan dalam respirasi seluler aerobik


• 95% energi tubuh manusia berasal dari respirasi seluler aerobik
• Organ dengan kandungan CoQ10 tinggi: jantung, liver, ginjal, dan
pankreas
• Semakin menua seseorang, CoQ10 semakin menurun dalam organ tubuh
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Fungsi-fungsi CoQ10 Dalam Tubuh

• Berperan dalam transpor elektron dan sintesis ATP dalam


membran mitochondria
• Produksi energi intraseluler
• Stabilisasi membran sel
• Menjaga integritas dan fungsi sel
• Berperan dalam regenerasi vitamin E
• Sangat esensial untuk fungsi normal myocardial
• Aktivitas sebagai imunostimulan

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Peranan CoQ10 dalam Sintesis ATP

• mitochondria (9)

• Rantai transpor elektron dengan “UQ” representasi peranan CoQ10


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Faktor-faktor mempengaruhi konsentrasi CoQ10

Berbagai faktor dapat menurunkan konsentrasi CoQ10 dalam organ:


• Asupan tidak mencukupi
• Produksi dalam tubuh tidak mencukupi, sebagai akibat:
- kebutuhan meningkat karena penyakit
- nutrisi lain diperlukan dalam sintesis tidak mencukupi, seperti
vitamin B2, vitamin B6, asam folat, vitamin B12, niasin,
asam pantotenat, dan vitamin C
• Penuaan/aging
• Paparan sinar UV (CoQ10 kulit ↓)
• Cacat genetik
• Interaksi dengan obat sehingga CoQ10 menurun; obat-obat yang
menurunkan CoQ10 meliputi beta-bloker, klonidin, gemfibrozil,
hidralazin, hidroklorotiazid, metildopa, obat statin, dan trisiklik
antidepresan

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Resiko defisiensi CoQ10

Penyakit yang diasosiasikan dengan level CoQ10


rendah:
• Gagal jantung kongestif
• Penyakit jantung iskhemik
• Cardiomyopathy
• Hipertensi
• Hipertiroidisme
• Kanker payudara

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Kandungan CoQ10 dalam Makanan
Jenis Makanan Kandungan CoQ10 Jenis Makanan Kandungan CoQ10
(mg/kg) (mg/kg)

Jantung sapi 113 Kacang tanah 27


Liver sapi 39 – 50 Biji almond 5 – 14
Daging sapi 26 – 40 Sayur brokoli 6–9
Ikan sarden 5 – 64 Sayur cauliflower 2 -7
Ikan salmon 4–8 Sayur bayam Sampai 10
Ikan tuna 5 Buah avocado 10
Minyak kedelai 54 – 280 Buah backcurrent 3
Minyak Olivarum 4 – 160 Buah strawberry 1
Minyak biji anggur 64 – 73 Buah jeruk 1–2
Minyak biji bunga 4 – 15 Buah apel 1
matahari

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Kemungkinan Penggunaan CoQ10
Kondisi/Penyakit Evidence

Antiaging/ Maximum life span manusia > 120 tahun; kecepatan aging dipengaruhi
↑Harapan Hidup efisiensi perbaikan DNA, tipe & kuantitas enzim antioksidan, dan
(HH) kecepatan produksi radikal bebas. CoQ10 → ↑HH tikus, mencit,
nematoda, dan ikan (dengan HH pendek)
Kardiovaskuler CoQ10 (424 pasien) memberikan keuntungan pada fungsi jantung

Gagal Jantung CoQ10 memberikan perbaikan CHF. Perbaikan pasien CHF signifikan
Kongestif (CHF) pada stroke volume, ejection fraction, cardiac output, cardiac index,
dan diastolic volume index
Angina CoQ10, menunda onset angina dan ↑stamina pasien. Pasien infark
myocardial (144, RCT) diberi CoQ10 (120 mg/hari, 28 hari) → perbaikan
signifikan: angina pectoris, total arrhythmia, dan fungsi poor left
ventricular.
Hipertensi Pasien hipertensi (83) diberi CoQ10 (2 x sehari 30mg) selama 12 minggu,
tekanan sistol turun 18 mmHg
Parkinson Dosis 1200mg/hari (9 bulan), pasien (80) mengalami perbaikan

Kanker Pemberian CoQ10 pada penderita kanker payudara, terjadi remisi atau
remisi parsial (RCT belum ada)
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Migraine INTERACTIONS
Tips for Avoiding Interactions
There are ways to avoid placing the body at risk of an unwanted nutrient-drug
interaction. The following are tips to remember about taking medications and
will help avoid interactions:

• Be sure to read the label on a prescription medicine and ask a pharmacist or


physician if something is not clear.
• Read all directions, warnings, and any possible side effects printed on all drug
labels and information in the package.
• Always take medications with a full glass of water.
• A drug may not work correctly if a medicine is taken improperly; do not stir
medication into food or take apart capsules (unless told to do so).
• Take vitamin and mineral supplements before or after medicine, as they may
interact with certain drugs.
• Avoid stirring drugs into hot drinks such as coffee because the drug's
effectiveness can be destroyed by the hot temperature.
• Do not drink alcohol when taking any medicine.
• Always tell a physician and pharmacist about all medicines being taken,
including both prescription and over-the-counter drugs.
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Questions To Ask Your Physician
• What is the medication for?
– Medication name
– Medication purpose
• How should I take the medication?
– How often, how long
– How to store
– Recommendations on consuming food and/or
beverages with medication
• What should I expect?
– Expected outcomes
– Precautions
– Side-effects

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The End
• Thanks for paying attention

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