Drug Interaction Report

MONITOR: Addition of an inotropic agent to ionic radiocontrast media may produce a paradoxical depressant response that can be deleterious to the ischemic myocardium. The exact mechanism of interaction is unknown, although ionic radiocontrast agents are known to have a direct depressant effect on cardiac muscles.

MANAGEMENT: Clinicians should be aware of this potential interaction when an inotropic agent is used in combination with ionic radiocontrast media. Patients should be monitored closely for adverse cardiac effects.

Administration of digoxin with a high-fiber meal has been shown to decrease its bioavailability by almost 20%. Fiber can sequester up to 45% of the drug when given orally. Patients should be advised to maintain a regular diet without significant fluctuation in fiber intake while digoxin is being titrated.

Grapefruit juice may modestly increase the plasma concentrations of digoxin. The mechanism is increased absorption of digoxin due to mild inhibition of intestinal P-glycoprotein by certain compounds present in grapefruits. In 12 healthy volunteers, administration of grapefruit juice with and 30 minutes before, as well as 3.5, 7.5, and 11.5 hours after a single digoxin dose (0.5 mg) increased the mean area under the plasma concentration-time curve (AUC) of digoxin by just 9% compared to administration with water. Moreover, P-glycoprotein genetic polymorphism does not appear to influence the magnitude of the effects of grapefruit juice on digoxin. Thus, the interaction is unlikely to be of clinical significance.