McKenna's Pharmacology, 2e

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P A R T 1  Introduction to nursing pharmacology

Drug–food interactions For the most part, a drug–food interaction occurs when the drug and the food are in direct contact in the stomach. Some foods increase acid production, speeding the breakdown of the drug molecule and preventing absorption and distribution of the drug. Some foods chemically react with certain drugs and prevent their absorption into the body. The antibiotic tetracycline cannot be taken with iron products for this reason. Tetracycline also binds with calcium to some extent and should not be taken with foods or other drugs contain­ ing calcium. Grapefruit juice has been found to affect liver enzyme systems for up to 48 hours after it has been ingested. This can result in increased or decreased serum levels of certain drugs. Many drugs come with the warning that they should not be combined with grape­ fruit juice. This drug–food interaction does not take place in the stomach, so the grapefruit juice needs to be avoided the entire time the drug is being used, not just while the drug is in the stomach. In most cases, oral drugs are best taken on an empty stomach. If the person cannot tolerate the drug on an empty stomach, the food selected for ingestion with the drug should be something that is known not to interact with it. Drug monographs usually list important drug–food interactions and give guidelines for avoiding problems and optimising the drug’s therapeutic effects. Drug–laboratory test interactions As explained previously, the body works through a series of chemical reactions. Because of this, adminis­ tration of a particular drug may alter results of clinical tests that are done as part of a diagnostic study. This drug–laboratory test interaction is caused by the drug being given and not necessarily by a change in the body’s responses or actions. Keep these interactions in mind when evaluating a person’s diagnostic tests. If one test result is altered and does not fit in with the clinical picture or other test results, consider the possibility of a drug–laboratory test interference. For example, dalteparin ( Fragmin ), a low-molecular-weight heparin used to prevent deep vein thrombosis after abdominal surgery, may cause increased levels of the liver enzymes aspartate aminotransferase (AST) and alanine ami­ notransferase (ALT) with no injury to liver cells or hepatitis. OPTIMAL THERAPEUTIC EFFECT As overwhelming as all of this information may seem, most people can follow a drug regimen to achieve optimal therapeutic effects without serious adverse effects. Avoiding problems is the best way to treat adverse or ineffective drug effects. One should incor­ porate basic history and physical assessment factors

• During distribution: One drug competes for the protein binding site of another drug, so the second drug cannot be transported to the responsive tissue. For example, aspirin competes with the drug methotrexate for protein-binding sites. Because aspirin is more competitive for the sites, the methotrexate is bumped off, resulting in increased release of methotrexate and increased toxicity to the tissues. • During biotransformation: One drug stimulates or blocks the metabolism of the other drug. For example, warfarin, an oral anticoagulant, is biotransformed more quickly if it is taken at the same time as barbiturates, rifampicin or many other drugs. Because the warfarin is biotransformed to an inactive state more quickly, higher doses will be needed to achieve the desired effect. People who use St John’s wort may experience altered effectiveness of several drugs that are affected by that herb’s effects on the liver. Cyclosporin, digoxin, theophylline, oral contraceptives, anticancer drugs, drugs used to treat HIV and antidepressants are all reported to have serious interactions with St John’s wort. • During excretion: One drug competes for excretion with the other drug, leading to accumulation and toxic effects of one of the drugs. For example, digoxin and quinidine are both excreted from the same sites in the kidney. If they are given together, the quinidine is more competitive for these sites and is excreted, resulting in increased serum levels of digoxin, which cannot be excreted. • At the site of action: One drug may be an antagonist of the other drug or may cause effects that oppose those of the other drug, leading to no therapeutic effect. This is seen, for example, when an antihypertensive drug is taken with an antiallergy drug that increases blood pressure. The effects on blood pressure are negated and there is a loss of the antihypertensive effectiveness of the drug. If a person is taking antidiabetic medication and also takes the herb ginseng, which lowers blood glucose levels, they may experience episodes of hypoglycaemia and loss of blood glucose control. Whenever two or more drugs are being given together, first consult a drug guide for a listing of clin­ ically significant drug–drug interactions. Sometimes problems can be avoided by staggering the administra­ tion of the drugs or adjusting their doses.

Safe medication administration

Always check the monograph of any drug that is being given to monitor for clinically important drug–drug, drug–alternative therapy or drug–food interactions.