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Grapefruit in Your Diet may Interfere with Certain Medications

The Statue of Liberty on Liberty Island in New York Harbor. (Dr. Noorali Bharwani)
The Statue of Liberty on Liberty Island in New York Harbor. (Dr. Noorali Bharwani)

“Our research group discovered the interaction between grapefruit and certain medications more than 20 years ago,” says an article in the Canadian Medical Association Journal (CMAJ March 5, 2013) written by Dr. David Bailey, Ph.D and his colleagues from Ottawa.

Certain other citrus fruits and products can interfere with several kinds of prescription pills. You are advised to check with your pharmacist and/or doctor before consuming any citrus products, including grapefruit, if you take prescription medications. Taking your medication and grapefruit product at different times does not stop the interaction.

Chemicals in the fruit can interfere with the enzymes that break down the medication in the digestive system. As a result, the medication may stay in your body for too short or too long a time. A medication that’s broken down too quickly won’t have time to work. On the other hand, a medication that stays in the body too long may build up to potentially dangerous levels.

There is a long list of medications that is affected by grapefruit and other citrus food. Here are some examples:

Antibiotics: erythromycin

Cholesterol reducing pills: atorvastatin (Lipitor), lovastatin (Altoprev), others

High blood pressure pills: felodipine, carvedilol (Coreg), others

Pills for heart problems: amiodarone (Coradarone, Pacerone)

Antidepressants: diazepam (Valium, Diastat), fluvoxamine, others

Pills to prevent organ rejection in transplant recipients: cyclosporine (Sandimmune and others)

Play it safe with prescription drugs. Always ask your doctor or pharmacist when you get a new prescription if it interacts with any foods or other medicines.

Many of the drugs that interact with grapefruit are highly prescribed and are essential for the treatment of important or common medical conditions. Currently, more than 85 drugs have the possibility of interacting with grapefruit; of these drugs, 43 have interactions that can result in serious adverse effects.

The chemicals in grapefruit involved in this interaction are the furanocoumarins.

One whole grapefruit or 200 mL of grapefruit juice is sufficient to cause clinically relevant increased systemic drug concentration and subsequent adverse effect. Seville oranges, often used in marmalades, limes and pomelo also produce this interaction.

In spite of the scientific evidence from reliable sources regarding adverse effects as discussed earlier, in routine clinical practice physicians do not see too many complications. One reason could be that multiple factors likely need to combine to achieve a marked increase in systemic drug concentration. It is reasonable to assume that just exposure to any interacting combination would not be sufficient to cause a clinically important change in drug response in all, if not most, cases.

Having said that, the fact remains you have to be vigilant. Pharmacists are the best source of information when it comes medications.

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Treating Men with Testosterone Deficiency can be Challenging

Statue of Abraham Lincoln at the Lincoln Memorial in Washington, D.C. (Dr. Noorali Bharwani)
Statue of Abraham Lincoln at the Lincoln Memorial in Washington, D.C. (Dr. Noorali Bharwani)

Testicles produce a hormone called testosterone that plays an important role in the masculine growth and development during puberty. Testosterone also plays an important role in the production of sperms. Poor testicular function results in erectile dysfunction (impotence). There is a failure to get and maintain an erection firm enough for sex.

Testosterone deficiency syndrome (i.e. poor testicular function) affects approximately 40 per cent of men aged 45 or older, although less than five per cent of these men are actually diagnosed and treated for the condition. It may affect multiple organ systems and can result in substantial health consequences for men.

Despite some controversy, testosterone therapy has been established as a safe and effective principal treatment for poor testicular function for nearly 70 years. But there is no consensus among experts on how and when to treat men with this condition.

A recent article in the Canadian Medical Association Journal (CMAJ December 8, 2015) welcomes the new Canadian guideline from the Canadian Men’s Health Foundation. It is hoped that the new guideline will clarify the management of this condition in the light of the huge volume of research on this topic over the last five years.

In the past there have been multiple guidelines from different groups like European Association of Urology, the International Society for Sexual Medicine, the International Society for the Study of the Aging Male (2008), and the Endocrine Society guidelines of 2010.

One cannot treat a condition if it is difficult to make a diagnosis. The diagnosis of testosterone deficiency syndrome is not straightforward, says the CMAJ article. The reasons are several. There are limitations to testosterone measurement and there is lack of a valid symptom score. This makes it difficult for the primary care physicians to make a diagnosis and start treatment. Especially when the experts cannot agree on values (normal vs. abnormal blood levels of testosterone).

The new guidelines do not define normal/abnormal blood levels for making a diagnosis of testosterone deficiency syndrome. Instead, the authors put weight on a combination of factors – clinical history, physical examination and response to therapy – in making the diagnosis, in addition to measuring testosterone level.

The European Association of Urology and the International Society for Sexual Medicine set parameters that men with a total testosterone level of less than 8 nmol/L will usually benefit from treatment. A trial of therapy may be indicated for those with levels between eight and 12 nmol/L in the presence of substantial symptoms.

There is no consensus on how long the initial trial of testosterone should last. The Canadian guideline advises a three-month trial of treatment. Some experts disagree with that. They suggest the trial should last six-months to 12-months.

Some other points of interest:

  • More than three-quarters of men with type 2 diabetes have erectile dysfunction, and about 90 per cent have positive symptom scores for testosterone deficiency syndrome.
  • Injection of testosterone, especially long-acting formulations, has higher efficacy rates and safety benefits than topical treatment. Other options are gels, patches or oral pills.
  • Opinion varies on monitoring patients taking testosterone therapy e.g. checking effects of testosterone on prostate (PSA).

It is important to remember that many important clinical issues remain unresolved. This article is just a summary of important points. The reader is advised to consult with his physician for more information.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Herbal remedies and vitamin supplements can be good, bad and ugly.

Cloud Gate, nicknamed The Bean, in Millenium Park, Chicago. (Dr. Noorali Bharwani)
Cloud Gate, nicknamed The Bean, in Millenium Park, Chicago. (Dr. Noorali Bharwani)

Recent CBC investigation report (Fifth Estate) revealed that herbal remedies and vitamins are frequently approved for sale in Canada with only minimal review. Even Health Canada acknowledges that their approval of these products is based on “weak evidence,” says the CBC report. That indeed is shocking.

The CBC report indicates that Health Canada approves more than 90 per cent of applications to sell new natural health products. And under updated rules, products can be approved in as little as 10 days.

Are we fully aware of the quality and safety of many of these supplements? The answer is no. We don’t. U.S. statistics show supplements send 23,000 people to hospital each year. Annual sales in Canada total about $1.4 billion, and Health Canada’s Natural and Non-Prescription Health Products directorate must approve supplements before they go on sale.

According to the CBC report, some leading researchers also say there is mounting evidence that many of the most popular supplements don’t live up to their claims and could even be dangerous. Common complaints about these products included contamination, purposeful adulteration, incorrect strength and incorrect identity.

Medically speaking a healthy individual, who eats a good diet, does not require vitamin supplements. But almost 30 percent of our population does not follow that dictum.

On the other hand, there is a consensus among medical experts that taking certain vitamin supplements on a daily basis does more good than harm.

Here are some examples:

  1. Folic acid (400 ug/day) reduces the risk of birth defects during pregnancy.
  2. Multivitamin tablet – one a day. Vitamin B such as B6 and B12, may help lower blood levels of a substance called homocysteine that may help reduce the risk of heart disease and stroke.
  3. Vitamin D (1000 – 2000 IU/day) minimizes the risk of osteoporosis and fractures and colon and breast cancer.
  4. Omega-3 fatty acids – 1000 mg/day or eat fish three times a week. This reduces the risk of sudden heart attack by 50 to 80 per cent. It can help ward off the serious heart rhythm disturbances associated with sudden cardiac death. It also appears to reduce the risk of strokes, mental decline in old age and prostate cancer.

In summary, one multivitamin, vitamin D and omega-3 should cover what you need if you are otherwise healthy. Remember, this is just a guideline. Discuss with your family doctor before you start these pills. If you opt to use herbal remedies for prevention or treatment of an illness check whether there is any science associated with the recommendation.

Vitamin supplement is just an icing on the cake – so to speak. Too much of icing and/or too much of cake is not good for your health!

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

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Auto-brewery syndrome – a rare condition where the body brews its own alcohol.

"Looking Into My Dreams, Awilda," is one of four large-scale portrait sculptures titled "Jamue Plensa: 1004 Portraits," in Millennium Park, Chicago. (Dr. Noorali Bharwani)
"Looking Into My Dreams, Awilda," is one of four large-scale portrait sculptures titled "Jamue Plensa: 1004 Portraits," in Millennium Park, Chicago. (Dr. Noorali Bharwani)

It was reported on CNN and now it is making rounds in the media. A woman in upstate New York was charged with DUI (driving under the influence) hours after her last drink.

The lady blew a blood alcohol level of nearly 0.40. The police procedure is to take the accused to a hospital, as that level is considered extremely life threatening.
The lady’s blood alcohol level in the hospital was 0.30. This was many hours after her last drink.

The lady was charged with DUI but a judge dismissed the charge after being presented with evidence the woman suffered from “auto-brewery syndrome.”

“I’m in touch with about 30 people who believe they have this same syndrome, about 10 of them are diagnosed with it,” says Panola College Dean of Nursing Barbara Cordell, who has studied the syndrome for years. “They can function at alcohol levels such as 0.30 and 0.40 when the average person would be comatose or dying. Part of the mystery of this syndrome is how they can have these extremely high levels and still be walking around and talking.” Cordell was quoted on CNN.

The condition is also known as gut-fermentation syndrome. This rare medical condition can occur when abnormal amounts of yeast in the gut convert common food carbohydrates into alcohol. The process is believed to take place in the small bowel.

The condition was first described in 1912 as “germ carbohydrate fermentation.” Since then, from time to time, it has surfaced in the media. In 2013, a case of a 61-year-old man who had frequent bouts of unexplained drunkenness for years was documented. Subsequently, he was diagnosed with an intestinal overabundance of Saccharomyces cerevisiae, or brewer’s yeast, the same yeast used to make beer.

CNN report says that the lady is treating her condition with anti-fungal medications and a yeast-free diet with absolutely no sugar, no alcohol and very low carbs. The report says that this does not work for everybody.

So I looked it up on Wikipedia.

The condition has been described variously. The self-brewery syndrome, intestinal fermentation syndrome, and gut syndrome fermentation is an intestinal disease and very poorly documented. There is no consensus among specialists.

The condition was described for the first time in 1976 in Japan. One case went unnoticed for 20 years, despite strong alcoholic intoxication following meals high in sugar or high in carbohydrates.

Symptoms of the disease can have a significant impact on daily life, says Wikipedia.  Recurrent symptoms such as dizziness, dry mouth, cold sweats, hangover, disorientation, irritable bowel syndrome, chronic fatigue syndrome, which can lead to other health problems such as depression and anxiety.

Is there a good treatment for it?

In general, the effects of the condition can be alleviated with a very low carbohydrate diet. The antifungal drug, fluconazole, can be an effective treatment against the disease since the drug is able to reduce Saccharomyces cerevisiae, responsible for fermentation in the gastrointestinal tract.

If you think you are suffering from auto-brewery syndrome, then to put it simply, don’t eat and drive.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!