Antibiotics and Drinking Alcohol

It is common to see “Avoid Alcohol” labels on prescription bottles. Many patients are concerned about mixing antibiotics with alcohol contained in beverages or other medications. In general, most antibiotics can be taken safely with small amounts of alcohol. Drinking excessive amounts of alcohol while fighting an infection may not be wise, can lead to dehydration, and may hinder the body’s natural ability to heal itself, as well.

Table 1 details some important antibiotic-alcohol drug interactions. In general, alcohol should be avoided when taking these antibiotics. Many over-the-counter medications (OTCs), such as cough or cold syrups may also contain alcohol in the formulation. The inactive ingredient listing can be checked to determine if alcohol is present, the label on the OTC bottle can be checked, or ask your physician or pharmacist. Prescription medications may also contain alcohol. Patients should check with their physician or pharmacist each time they receive a new prescription to determine if there are important drug interactions. A drug interaction checker to review drug combinations can give additional information.

One of the most common alcohol-antibiotic interactions is with the antimicrobial agent metronidazole (Flagyl). Metronidazole is used for a variety of infections, including gastrointestinal, skin, joint and respiratory tract infections. Taking metronidazole with alcohol may result in a reaction called a “disulfiram-like reaction”. A “disulfiram-like reaction”  may include nausea, flushing of the skin, stomach cramps, vomiting, headaches, rapid heart rate, and difficulty breathing.[1] A similar reaction may occur with other antibiotics.

Certain antibiotics may also lead to central nervous system (CNS) side effects, such as drowsiness, sedation, dizziness or confusion. Alcohol is also considered a CNS depressant. When alcohol is combined with antibiotics that also have a CNS depressant effect, additive effects may occur. These effects can be serious if driving, in the elderly, and in patients who may take other CNS depressant medications, such as opioid pain relievers, anxiety or seizures medications, among others.

Alcohol is metabolized (broken down) in the liver by an enzyme called cytochrome P450 2C9. Some drugs are also metabolized by the 2C9 enzyme. Depending upon how often and how much alcohol is consumed, this enzyme may affect how drugs are metabolized. When an intoxicating, acute amount of alcohol is consumed, the 2C9 enzyme is “inhibited”, meaning that it cannot metabolize drugs that require this enzyme as efficiently as normal. The levels of the drug in the body may increase because it is not fully metabolized and excreted. This could lead to drug toxicity and side effects. Alternatively, when alcohol is abused chronically, as may occur with an alcoholic, levels of the 2C9 enzyme may become “induced”, meaning that metabolizing is occurring at a more efficient rate, and drug levels may decrease. The therapeutic effect that is desired may not occur with lowered drug levels in the body.[1][2][3]

Significant Antimicrobial-Alcohol Drug Interactions

Interacting Drug Effect Recommendation
metronidazole (Flagyl, Flagyl ER); metronidazole vaginal disulfiram-like reaction: abdominal cramps, nausea, vomiting, headaches, flushing may occur; also possible with systemic absorption of vaginal cream
avoid combination with alcohol during treatment and for 72 hours after discontinuation of metronidazole treatment.
tinidazole (Tindamax) disulfiram-like reaction which may include abdominal cramps, nausea, vomiting, headaches, flushing
avoid combination with alcohol during treatment and for 72 hours after discontinuation of tinidazole treatment.
cefotetan disulfiram-like reaction which may include flushing, sweating, headache, tachycardia (rapid heart rate) avoid combination with alcohol during treatment and for 72 hours after discontinuation of cefotetan
cycloserine combination may increase risk of central nervous system toxicity; possible seizures avoid alcohol while taking cycloserine
ethionamide combination may increase risk of central nervous system toxicity; possible psychosis avoid alcohol while taking ethionamide
isoniazid increased risk of liver toxicity if daily alcohol consumption avoid alcohol while taking isoniazid
linezolid increased risk of hypertensive crisis (dangerous elevated blood pressure) avoid large quantities of tyramine-containing alcoholic beverages (tap beer, red wine)
voriconazole (antifungal) combination with alcohol may either increase or decrease voriconazole levels due to altered liver metabolism avoid voriconazole with chronic or acute excessive alcohol use
pyrazinamide combination with alcohol may increase risk for liver toxicity use caution; avoid use in alcoholics or with chronic daily alcohol use
thalidomide combination with alcohol may increase risk for additive sedation, drowsiness, confusion, motor skills; use caution if driving avoid alcohol while taking thalidomide
rifampin combination with alcohol may increase risk for liver toxicity use caution; avoid use in alcoholics or with chronic daily alcohol use
didanosine combination with alcohol may increase risk for pancreatitis use caution; avoid use in alcoholics or with chronic daily alcohol use

See Also:

References:

[1] Lwanga, J; Mears, A; Bingham, J S; Bradbeer, C S (16 December 2008). "Do antibiotics and alcohol mix? The beliefs of genitourinary clinic attendees". British Medical Journal 337: a2885.

[2] Hansten P, Horn J. The Top 100 Drug Interactions, A Guide to Patient Management. 2010 Edition. H&H Publications, LLP. Freeland, WA.

[3] NHS Choices. Can I drink alcohol while taking antibiotics? 7/15/2011. Acessed 11/3/2011. http://www.nhs.uk/chq/pages/871.aspx

Last updated: 2013-06-16 by Leigh Anderson, PharmD.

Hide
(web5)