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Drug Interactions between Adlone-40 and licorice

This report displays the potential drug interactions for the following 2 drugs:

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Interactions between your drugs

Moderate

methylPREDNISolone licorice

Applies to: Adlone-40 (methylprednisolone) and licorice

GENERALLY AVOID: Licorice may potentiate the effects of corticosteroids. Licorice use has been associated with hypertension as well as sodium and water retention. Glycyrrhizic acid, a component of licorice, is hydrolyzed in the intestine to a metabolite (glycyrrhetinic acid) that causes mineralocorticoid and renin-suppressing effects. In one study, licorice was found to increase blood pressure in a dose-dependent manner. Healthy volunteers who consumed licorice 50 to 200 g/day (corresponding to 75 to 540 mg/day of glycyrrhetinic acid) for two to four weeks had a 3.1 to 14.4 mmHg increase in their systolic blood pressure. Even the lowest dosage demonstrated a significant effect. In another study, plasma potassium levels decreased by 0.3 to 1.5 mEq/L in 12 out of 14 healthy volunteers who ingested licorice 100 or 200 g/day (equivalent to 700 to 1400 mg/day of glycyrrhizic acid) for one to four weeks, including four who had to be withdrawn from the study because of hypokalemia. Two more subjects were withdrawn due to edema of the face, hands, and ankles. Other side effects reported include mild, transient generalized edema; headache; sodium retention; and weight gain (1 to 4 kg, mean 1.5 kg). Signs of renin-angiotensin-aldosterone suppression were observed in all subjects, especially plasma renin activity and urinary aldosterone concentrations, which fell to subnormal or undetectable levels in the majority of subjects. There have been various published case reports of refractory hypertension, severe hypokalemia (life-threatening hypokalemic paralysis, myopathy, arrhythmia, or cardiac arrest), and hypertensive encephalopathy in association with licorice intoxication. Hypertension and hypokalemia have also been reported with moderate doses of licorice in the form of licorice-flavored chewing gum or candy, chewing tobacco, or licorice-based foods and beverages consumed on a chronic basis. Prolonged use of licorice has led to a hypermineralocorticoid (pseudohyperaldosteronism) syndrome characterized by hypertension, hypernatremia, hypokalemia, metabolic alkalosis, renin-angiotensin-aldosterone suppression, and edema. In studies and case reports, licorice toxicity has generally been completely reversible within one to several weeks of licorice discontinuation. However, renin-angiotensin-aldosterone axis may be suppressed for up to several months.

MANAGEMENT: Patients receiving prolonged corticosteroid therapy should avoid or limit the consumption of licorice-containing products. Even relatively moderate doses of licorice may be problematic in susceptible patients when ingested regularly for prolonged periods.

References

  1. Ishikawa S, Kato M, Tokuda T, Momoi H, Sekijima Y, Higuchi M, Yanagisawa N (1999) "Licorice-induced hypokalemic myopathy and hypokalemic renal tubular damage in anorexia nervosa." Int J Eating Disorder, 26, p. 111-4
  2. Fugh-Berman A (2000) "Herb-drug interactions." Lancet, 355, p. 134-8
  3. Cumming AM, Boddy K, Brown JJ, et al. (1980) "Severe hypokalaemia with paralysis induced by small doses of liquorice." Postgrad Med J, 56, p. 526-9
  4. Cumming A (1976) "Severe reduction of serum potassium induced by licorice." Nurs Times, 72, p. 367-70
  5. de Klerk GJ, Nieuwenhuis MG, Beutler JJ (1997) "Lesson of the week: hypokalaemia and hypertension associated with use of liquorice flavoured chewing gum." BMJ, 314, p. 731
  6. Edwards CR (1991) "Lessons from licorice." N Engl J Med, 325, p. 1242-3
  7. Stewart PM, Wallace AM, Valentino R, Burt D, Shackleton CH, Edwards CR (1987) "Mineralocorticoid activity of liquorice: 11-beta-hydroxysteroid dehydrogenase deficiency comes of age." Lancet, 2, p. 821-4
  8. Nielsen I, Pedersen RS (1984) "Life-threatening hypokalaemia caused by liquorice ingestion." Lancet, 1, p. 1305
  9. Rosseel M, Schoors D (1993) "Chewing gum and hypokalaemia." Lancet, 341, p. 175
  10. Clyburn EB, DiPette DJ (1995) "Hypertension induced by drugs and other substances." Semin Nephrol, 15, p. 72-86
  11. Farese RV, Biglieri EG, Shackleton CH, Irony I, Gomez-Fontes R (1991) "Licorice-induced hypermineralocorticoidism." N Engl J Med, 325, p. 1223-7
  12. Elinav E, Chajek-Shaul T (2003) "Licorice consumption causing severe hypokalemic paralysis." Mayo Clin Proc, 78, p. 767-8
  13. Richard CL, Jurgens TM (2005) "Effects of natural health products on blood pressure." Ann Pharmacother, 39, p. 712-20
  14. Sigurjonsdottir HA, Franzson L, Manhem K, Ragnarsson J, Sigurdsson G, Wallerstedt S (2001) "Liquorice-induced rise in blood pressure: a linear dose-response relationship." J Hum Hypertens, 15, p. 549-52
  15. Dellow EL, Unwin RJ, Honour JW (1999) "Pontefract cakes can be bad for you: refractory hypertension and liquorice excess." Nephrol Dial Transplant, 14, p. 218-20
  16. Epstein MT, Espiner EA, Donald RA, Hughes H (1977) "Effect of eating liquorice on the renin-angiotensin aldosterone axis in normal subjects." Br Med J, 1, p. 488-90
  17. Epstein MT, Espiner EA, Donald RA, Hughes H (1977) "Liquorice toxicity and the renin-angiotensin-aldosterone axis in man." Br Med J, 1, p. 209-10
  18. Cumming AM (1977) "Metabolic effects of licorice." Br Med J, 1, p. 906
  19. Bannister B, Ginsburg R, Shneerson J (1977) "Cardiac arrest due to liquorice-induced hypokalaemia." Br Med J, 2, p. 738-9
  20. Holmes AM, Young J, Marrott PK, Prentice E (1970) "Pseudohyperaldosteronism induced by habitual ingestion of liquorice." Postgrad Med J, 46, p. 625-9
View all 20 references

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Drug and food interactions

Moderate

methylPREDNISolone food

Applies to: Adlone-40 (methylprednisolone)

MONITOR: Grapefruit juice may increase the plasma concentrations of orally administered drugs that are substrates of the CYP450 3A4 isoenzyme. The proposed mechanism is inhibition of CYP450 3A4-mediated first-pass metabolism in the gut wall by certain compounds present in grapefruit. Because grapefruit juice inhibits primarily intestinal rather than hepatic CYP450 3A4, the magnitude of interaction is greatest for those drugs that undergo significant presystemic metabolism by CYP450 3A4 (i.e., drugs with low oral bioavailability). In general, the effect of grapefruit juice is concentration-, dose- and preparation-dependent, and can vary widely among brands. Certain preparations of grapefruit juice (e.g., high dose, double strength) have sometimes demonstrated potent inhibition of CYP450 3A4, while other preparations (e.g., low dose, single strength) have typically demonstrated moderate inhibition. Pharmacokinetic interactions involving grapefruit juice are also subject to a high degree of interpatient variability, thus the extent to which a given patient may be affected is difficult to predict.

MANAGEMENT: Patients who regularly consume grapefruit or grapefruit juice should be monitored for adverse effects and altered plasma concentrations of drugs that undergo significant presystemic metabolism by CYP450 3A4. Grapefruit and grapefruit juice should be avoided if an interaction is suspected. Orange juice is not expected to interact with these drugs.

References

  1. Edgar B, Bailey D, Bergstrand R, et al. (1992) "Acute effects of drinking grapefruit juice on the pharmacokinetics and dynamics on felodipine and its potential clinical relevance." Eur J Clin Pharmacol, 42, p. 313-7
  2. Jonkman JH, Sollie FA, Sauter R, Steinijans VW (1991) "The influence of caffeine on the steady-state pharmacokinetics of theophylline." Clin Pharmacol Ther, 49, p. 248-55
  3. Bailey DG, Arnold JM, Munoz C, Spence JD (1993) "Grapefruit juice--felodipine interaction: mechanism, predictability, and effect of naringin." Clin Pharmacol Ther, 53, p. 637-42
  4. Bailey DG, Arnold JMO, Spence JD (1994) "Grapefruit juice and drugs - how significant is the interaction." Clin Pharmacokinet, 26, p. 91-8
  5. Sigusch H, Hippius M, Henschel L, Kaufmann K, Hoffmann A (1994) "Influence of grapefruit juice on the pharmacokinetics of a slow release nifedipine formulation." Pharmazie, 49, p. 522-4
  6. Bailey DG, Arnold JM, Strong HA, Munoz C, Spence JD (1993) "Effect of grapefruit juice and naringin on nisoldipine pharmacokinetics." Clin Pharmacol Ther, 54, p. 589-94
  7. Yamreudeewong W, Henann NE, Fazio A, Lower DL, Cassidy TG (1995) "Drug-food interactions in clinical practice." J Fam Pract, 40, p. 376-84
  8. (1995) "Grapefruit juice interactions with drugs." Med Lett Drugs Ther, 37, p. 73-4
  9. Hukkinen SK, Varhe A, Olkkola KT, Neuvonen PJ (1995) "Plasma concentrations of triazolam are increased by concomitant ingestion of grapefruit juice." Clin Pharmacol Ther, 58, p. 127-31
  10. Min DI, Ku YM, Geraets DR, Lee HC (1996) "Effect of grapefruit juice on the pharmacokinetics and pharmacodynamics of quinidine in healthy volunteers." J Clin Pharmacol, 36, p. 469-76
  11. Majeed A, Kareem A (1996) "Effect of grapefruit juice on cyclosporine pharmacokinetics." Pediatr Nephrol, 10, p. 395
  12. Clifford CP, Adams DA, Murray S, Taylor GW, Wilkins MR, Boobis AR, Davies DS (1996) "Pharmacokinetic and cardiac effects of terfenadine after inhibition of its metabolism by grapefruit juice." Br J Clin Pharmacol, 42, p662
  13. Josefsson M, Zackrisson AL, Ahlner J (1996) "Effect of grapefruit juice on the pharmacokinetics of amlodipine in healthy volunteers." Eur J Clin Pharmacol, 51, p. 189-93
  14. Kantola T, Kivisto KT, Neuvonen PJ (1998) "Grapefruit juice greatly increases serum concentrations of lovastatin and lovastatin acid." Clin Pharmacol Ther, 63, p. 397-402
  15. Ozdemir M, Aktan Y, Boydag BS, Cingi MI, Musmul A (1998) "Interaction between grapefruit juice and diazepam in humans." Eur J Drug Metab Pharmacokinet, 23, p. 55-9
  16. Bailey DG, Malcolm J, Arnold O, Spence JD (1998) "Grapefruit juice-drug interactions." Br J Clin Pharmacol, 46, p. 101-10
  17. Bailey DG, Kreeft JH, Munoz C, Freeman DJ, Bend JR (1998) "Grapefruit juice felodipine interaction: Effect of naringin and 6',7'-dihydroxybergamottin in humans." Clin Pharmacol Ther, 64, p. 248-56
  18. Garg SK, Kumar N, Bhargava VK, Prabhakar SK (1998) "Effect of grapefruit juice on carbamazepine bioavailability in patients with epilepsy." Clin Pharmacol Ther, 64, p. 286-8
  19. Lilja JJ, Kivisto KT, Neuvonen PJ (1998) "Grapefruit juice-simvastatin interaction: Effect on serum concentrations of simvastatin, simvastatin acid, and HMG-CoA reductase inhibitors." Clin Pharmacol Ther, 64, p. 477-83
  20. Fuhr U, Maier-Bruggemann A, Blume H, et al. (1998) "Grapefruit juice increases oral nimodipine bioavailability." Int J Clin Pharmacol Ther, 36, p. 126-32
  21. Lilja JJ, Kivisto KT, Neuvonen PJ (1999) "Grapefruit juice increases serum concentrations of atorvastatin and has no effect on pravastatin." Clin Pharmacol Ther, 66, p. 118-27
  22. Eagling VA, Profit L, Back DJ (1999) "Inhibition of the CYP3A4-mediated metabolism and P-glycoprotein-mediated transport of the HIV-I protease inhibitor saquinavir by grapefruit juice components." Br J Clin Pharmacol, 48, p. 543-52
  23. Damkier P, Hansen LL, Brosen K (1999) "Effect of diclofenac, disulfiram, itraconazole, grapefruit juice and erythromycin on the pharmacokinetics of quinidine." Br J Clin Pharmacol, 48, p. 829-38
  24. Lee AJ, Chan WK, Harralson AF, Buffum J, Bui BCC (1999) "The effects of grapefruit juice on sertraline metabolism: An in vitro and in vivo study." Clin Ther, 21, p. 1890-9
  25. Dresser GK, Spence JD, Bailey DG (2000) "Pharmacokinetic-pharmacodynamic consequences and clinical relevance of cytochrome P450 3A4 inhibition." Clin Pharmacokinet, 38, p. 41-57
  26. Gunston GD, Mehta U (2000) "Potentially serious drug interactions with grapefruit juice." S Afr Med J, 90, p. 41
  27. Takanaga H, Ohnishi A, Maatsuo H, et al. (2000) "Pharmacokinetic analysis of felodipine-grapefruit juice interaction based on an irreversible enzyme inhibition model." Br J Clin Pharmacol, 49, p. 49-58
  28. Libersa CC, Brique SA, Motte KB, et al. (2000) "Dramatic inhibition of amiodarone metabolism induced by grapefruit juice." Br J Clin Pharmacol, 49, p. 373-8
  29. Bailey DG, Dresser GR, Kreeft JH, Munoz C, Freeman DJ, Bend JR (2000) "Grapefruit-felodipine interaction: Effect of unprocessed fruit and probable active ingredients." Clin Pharmacol Ther, 68, p. 468-77
  30. Zaidenstein R, Soback S, Gips M, Avni B, Dishi V, Weissgarten Y, Golik A, Scapa E (2001) "Effect of grapefruit juice on the pharmacokinetics of losartan and its active metabolite E3174 in healthy volunteers." Ther Drug Monit, 23, p. 369-73
  31. Sato J, Nakata H, Owada E, Kikuta T, Umetsu M, Ito K (1993) "Influence of usual intake of dietary caffeine on single-dose kinetics of theophylline in healthy human subjects." Eur J Clin Pharmacol, 44, p. 295-8
  32. Flanagan D (2005) "Understanding the grapefruit-drug interaction." Gen Dent, 53, 282-5; quiz 286
View all 32 references

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Therapeutic duplication warnings

No warnings were found for your selected drugs.

Therapeutic duplication warnings are only returned when drugs within the same group exceed the recommended therapeutic duplication maximum.

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Drug Interaction Classification

These classifications are only a guideline. The relevance of a particular drug interaction to a specific individual is difficult to determine. Always consult your healthcare provider before starting or stopping any medication.
Major Highly clinically significant. Avoid combinations; the risk of the interaction outweighs the benefit.
Moderate Moderately clinically significant. Usually avoid combinations; use it only under special circumstances.
Minor Minimally clinically significant. Minimize risk; assess risk and consider an alternative drug, take steps to circumvent the interaction risk and/or institute a monitoring plan.
Unknown No interaction information available.

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