This transcript is automatically generated.
00:00:05 Narrator
Welcome to Rumor vs Truth, your trusted source for facts… where we dissect the evidence behind risky rumors and reveal clinical truths. Today we’ll quench your thirst for knowledge about some juicy medication interactions.
00:00:22 Stephen Small
So this is our first episode of Rumor vs Truth by TRC Healthcare, where we're going to dive into the evidence behind some of those clinical conundrums you face to see if they're actually based on evidence or just hearsay.
00:00:35 Don Weinberger
You probably heard a pharmacist letter and prescriber insights products.
00:00:38 Don Weinberger
And now we're adding this podcast series to help pharmacists, pharmacy technicians, prescribers, and even patients navigate some of the claims they might see about medication therapy.
00:00:48 Don Weinberger
You know, as pharmacists were trained to help clear up some of those rumors and identify the truths.
00:00:53 Stephen Small
That's right Don, and for those who don't know me, I'm Steve the Pharmacist.
00:00:57 Stephen Small
I'm an editor here since 2024 and I've actually been in practice in hospital pharmacies since 2015, mostly specialized in pediatrics and obstetrics.
00:01:07 Don Weinberger
And I'm Don the Pharmacist. I've been here at TRC since 2015 and I've been in practice as a pharmacist in both community and hospital pharmacies since 2013.
00:01:17 Stephen Small
And in this episode, we're actually going to be talking about juicy interactions with meds to see if some of those claims out there are actually worth the squeeze.
00:01:27 Don Weinberger
And we've gotten a lot of questions from our readers about this, so obviously there's a thirst for knowledge out there, buckle up folks, the puns are just going to keep coming.
00:01:38 Stephen Small
And here's one that's low hanging fruit.
00:01:41 Stephen Small
You can't drink grapefruit juice with certain meds like statins. And actually, a few days ago I was able to speak with one of our editor colleagues here about this very topic. Let's roll the tape.
00:01:54 Stephen Small
All right, so I'm joined today by Gina, one of our assistant editors here at Pharmacist’s Letter. Hi, Gina.
00:02:00 Gina Corley
Hi.
00:02:01 Stephen Small
Thanks for joining us and you're kind of our juice guru on staff.
00:02:04 Stephen Small
In fact, you just wrote an article about this, so I'm so glad you can give us your thoughts on this.
00:02:09 Gina Corley
Yeah. Thank you.
00:02:11 Stephen Small
So what is the mechanism behind grapefruit juice and this interaction with, with statins?
00:02:17 Gina Corley
Yeah. So certain stat, certain statins, specifically simvastatin, atorvastatin and lovastatin are metabolized by it by an enzyme called Sip 3A4.
00:02:30 Gina Corley
And grapefruit juice actually inhibits this, this enzyme, which means that it's going to block enzymes that breakdown these, these statins and result in higher drug levels.
00:02:42 Stephen Small
OK, nice. And what is the evidence behind this, is it all just theoretical or do we actually have data backing this up?
00:02:49 Gina Corley
Yeah. So we first learned that grapefruits can can interact with drugs back in the 19… in the 1980s.
00:02:56 Gina Corley
And since then, you know, we've done numerous research on it and we found that some studies involving grapefruit juice and statins say that it's actually OK to drink an 8 oz glass of juice, and it might even help patients lower.
00:03:11 Gina Corley
Their LDL cholesterol without causing any increase in muscle pain.
00:03:16 Gina Corley
But the problem is that a lot of these studies aren't really robust.
00:03:22 Gina Corley
So for for instance, some of them involve like 10 patients that were all in in their 20s and some lasted only a week.
00:03:30 Gina Corley
And then others involved giving patients like the equivalent of 6 whole grapefruits worth of juice.
00:03:39 Stephen Small
That sounds like a lot of juice.
00:03:39 Gina Corley
Yeah, so it's. Yeah. So. So really, what we need is we need, we need studies done in the correct patient population.
00:03:48 Gina Corley
That are larger, you know, to really get a better understanding of is this interaction less of a risk than we have always thought.
00:03:58 Stephen Small
Wow, so with all that that we do know, what should we be recommending to patients and who are taking statins but are huge fans of grapefruit juice?
00:04:05 Stephen Small
What do we do in that instance?
00:04:07 Gina Corley
Yeah. So I would say that one glass likely won't hurt.
00:04:12 Gina Corley
Patients should, of course, monitor themselves for any muscle aches or pain, since this is the most common thing that they would experience.
00:04:21 Gina Corley
But keep in mind too, this is only for simvastatin, atorvastatin and lovastatin, so patients can even talk to their prescriber about switching to something like rosuvastatin or pravastatin, you know a statin that does not get metabolized by sip 3A four and therefore would not interact with grapefruit juice.
00:04:44 Stephen Small
Excellent. That's super helpful. And thank you again for all your expertise and I'm looking forward your article.
00:04:49 Gina Corley
Thank you.
00:04:50 Stephen Small
You have some great tidbits and more on juice interactions and that so our readers will love that.
00:04:56 Gina Corley
Thank you.
00:05:03 Don Weinberger
Wow, she's a smart apple, huh? Thanks for giving your thoughts, Gina.
00:05:07 Don Weinberger
Especially clarification on which statins are affected and the amounts of grapefruit juice needed for this effect.
00:05:13 Don Weinberger
The claim here is you can't drink grapefruit juice with certain meds like statins.
00:05:19 Don Weinberger
Thus, the verdict is dramatically.
00:05:24 Don Weinberger
True, but with conditions.
00:05:29 Stephen Small
And there are some other meds that you can't take with fruit juices, and I think ones that we think of off the top of our head are like dexa phenadine or Allegra. Right. Don, I'm thinking about Apple and grapefruit and orange juice.
00:05:40 Stephen Small
This one I'm kind of looking at the data behind this.
00:05:43 Stephen Small
Was able to find.
00:05:44 Stephen Small
12016 study but only had 10 patients and they received apple juice or water up to 600 MLS after getting a one time dose of fexofenadine and they found that that small 150 mill volume really didn't do a whole lot.
00:06:01 Stephen Small
But the larger volumes decrease the AUC by 30 to 60%.
00:06:06 Stephen Small
And they think maybe that had to do with inhibiting the transporter protein forfex of benadine from the gut.
00:06:13 Stephen Small
It's hard to say.
00:06:15 Don Weinberger
Hold on, Steve. What exactly is AUC?
00:06:18 Stephen Small
Oh, that's that's a really good point.
00:06:20 Stephen Small
So for those listeners who aren't familiar with an AUC that stands for area under the curve.
00:06:26 Stephen Small
So if you imagine a drugs concentration in the body plotted over time on a graph, right?
00:06:32 Stephen Small
We're literally talking about all the area below that line.
00:06:36 Stephen Small
And pretty much it represents the overall exposure to Ahmed.
00:06:40 Stephen Small
So the higher the number, that means more drug exposure overall for that patient.
00:06:45 Stephen Small
And here, though, the apple juice decreased the.
00:06:48 Stephen Small
So that means that it lower the exposure, which might not be a good thing. And when we're thinking about other juices, there was actually a 2002 study I found again with only 10 folks.
00:07:00 Stephen Small
Where they got fexofenadine for a dose and they gave these patients up to 1.2 liters of grapefruit, orange apple juice or water.
00:07:09 Stephen Small
And they gave it over three hours, and it turns out all those juices decrease the AUC there.
00:07:14 Stephen Small
By 30 to 40% also. So I would say the cherry on top here is that we're not really sure if this made a clinical difference.
00:07:23 Stephen Small
So just because we're changing drug levels in the body doesn't mean we actually changed how that drug is actually treating symptoms. For example, they didn't look at allergy symptoms when these studies, so kind of hard to say.
00:07:33 Stephen Small
So then when it comes to the claim that there are other meds, you can't take the fruit juices specifically fexofenadine. Here I would say that the verdict is.
00:07:45 Stephen Small
True, but with conditions probably.
00:07:48 Stephen Small
Here's my thought, Don.
00:07:49 Stephen Small
That it's.
00:07:50 Stephen Small
But these volumes are pretty astounding and frankly, a little bit aggressive, right?
00:07:54 Stephen Small
1.2 liters of fruit juice seems really crazy to me.
00:07:59 Don Weinberger
Yeah.
00:08:00 Don Weinberger
For someone who doesn't like grapefruit juice, that seems almost.
00:08:02 Stephen Small
Impossible. Yeah, that's your nightmare.
00:08:07 Don Weinberger
Good thoughts.
00:08:10 Don Weinberger
So we've cherry picked another one here. I warned you folks about the puns.
00:08:13 Don Weinberger
You're trapped with us.
00:08:14 Don Weinberger
So this one this rumor is can juices affect absorption of ADHD stimulants like Adderall for example?
00:08:23 Don Weinberger
You know this good question, because grabbing a glass of orange juice or apple juice in the morning with an ADHD stimulant medication probably happens a lot.
00:08:33 Don Weinberger
And yes, it does affect absorption, but not really on the same mechanism as the stats and the grapefruits.
00:08:39 Don Weinberger
Were.
00:08:41 Don Weinberger
So the Jews itself, especially ones that have fortified with the vitamin C, can actually work against the stimulant effectiveness.
00:08:47 Don Weinberger
First, you know juices affect the acidity of the stomach, which actually lowers the absorption of the stimulants.
00:08:53 Don Weinberger
But also second, they increase the acidity of the urine itself.
00:08:58 Don Weinberger
Which increases the amount of stimulant that's actually excreted from the body.
00:09:01 Don Weinberger
So patients do complain, you know, about the semen is not working.
00:09:06 Don Weinberger
It's maybe not lasting long throughout the day.
00:09:10 Don Weinberger
Their juice consumption actually may be to blame to ensure proper absorption.
00:09:14 Don Weinberger
You know, maybe prudent to separate those. The juice consumption by either one hour before one hour, 1 hour after taking that medication.
00:09:23 Stephen Small
Yeah, that's a really good point about spacing.
00:09:25 Stephen Small
Didn't think about that.
00:09:27 Don Weinberger
Yep, definitely.
00:09:28 Don Weinberger
So the claim here is can juices affect absorption of certain ADHD stimulants like Adderall and the verdict here is.
00:09:41 Don Weinberger
True. So yeah, so those juices, especially ones that fortified with vitamin C, can affect those absorption of certain amphetamine like ADHD stimulants.
00:09:54 Stephen Small
Nice. Yeah, I could definitely see that making sense there and some patients might be asking about sildenafil or Viagra, which could be affected by more exotic juices here, like Seville oranges, pomegranates or pomellos.
00:10:09 Don Weinberger
Wait a?
00:10:09 Don Weinberger
What's what is a pomello?
00:10:12 Stephen Small
I honestly wasn't too sure myself.
00:10:14 Stephen Small
Believe it or not, my brother is a chef.
00:10:16 Stephen Small
And just the other day, he gave me a pomelo to.
00:10:19 Stephen Small
It's essentially a relative of a grapefruit, but it's kind of just a similar taste, maybe a bit sweeter.
00:10:24 Stephen Small
What did you think it was, Don?
00:10:26 Stephen Small
Curious what you thought that was.
00:10:28 Stephen Small
It's a fruit.
00:10:30 Don Weinberger
I would guess probably like a hybrid between a pomegranate and a melon based off of the.
00:10:35 Don Weinberger
But the.
00:10:36 Don Weinberger
That it tastes like grapefruit. I won't be touching it.
00:10:36 Stephen Small
Yeah.
00:10:36 Stephen Small
Means just so much.
00:10:39 Don Weinberger
Right.
00:10:40 Stephen Small
Well, the idea here is that maybe that pomelo creates a physical chemical.
00:10:45 Stephen Small
Or maybe it pushes out the the sildenafil back into the gut through maybe a transporter protein.
00:10:53 Stephen Small
They've done some small studies with this.
00:10:55 Stephen Small
One in 2009 took 6.
00:10:56 Stephen Small
Gave them some sildenafil for one dose, and they gave them either pomello juice or water.
00:11:01 Stephen Small
It actually decreased the Max concentration of the body and decrease the AUC to only 60% compared to water.
00:11:08 Stephen Small
But just like we saw before, they didn't measure any.
00:11:11 Stephen Small
For example, here they didn't measure sexual performance, which is what we'd be worried about, right? If we're decreasing levels.
00:11:18 Stephen Small
And then Seville oranges are.
00:11:20 Stephen Small
Kind of like grapefruit. They also inhibit sip 3A four in the liver.
00:11:24 Stephen Small
So here they did a similar study in 2016 with 9 males and they gave them 250 MLS of water, lemon juice or Seville oranges.
00:11:33 Stephen Small
For three days and then on that third day, they gave a dose of that sildenafil and found that it actually increased the AUC by over 40%.
00:11:41 Stephen Small
But here again, they didn't see if there was any effect on sexual performance either.
00:11:46 Stephen Small
One adverse effect we worry about is priapism, which they didn't see.
00:11:50 Stephen Small
And then we were talking about pomegranate juice earlier, which is very popular with some of the.
00:11:56 Stephen Small
I'm friends with and there are actually 3 case reports of Pripism taking sildenafil with pomegranate juice and one patient only needed to take 250 M LS.
00:12:06 Stephen Small
Doesn't sound like a whole lot.
00:12:08 Stephen Small
And all these patients need a medical intervention.
00:12:10 Stephen Small
They had to go to the emergency department from mixing this juice with sildenafil. So if you have patients coming to you asking if they can take sildenafil with more exotic juice.
00:12:20 Stephen Small
Here I would say the verdict here is.
00:12:27 Stephen Small
True, but with conditions.
00:12:30 Stephen Small
We know that with pomegranate juice, it may actually lead to some adverse effects based on case reports and we do know these other juices do affect some of the drug levels, but we don't know if they actually affect sexual performance or other adverse effects. So there you go.
00:12:44 Don Weinberger
And thank you for educating me on what a pomelo is.
00:12:47 Don Weinberger
Won't.
00:12:48 Don Weinberger
Eating that either.
00:12:49 Stephen Small
Learning something new every day, Don.
00:12:53 Stephen Small
So we've also gotten some folks who write in asking if fruit juices are actually good for certain meds, which is kind of a good point, right?
00:13:02 Stephen Small
Fruit juices are supposed to be natural product and things like that.
00:13:06 Stephen Small
One example I could think of is acidic juices. Do help absorb iron. A very common Med in Pediatrics where I practice in.
00:13:13 Stephen Small
And orange juice, for example, increases iron absorption by 40%.
00:13:18 Stephen Small
It keeps that iron in the fairest state rather than the ferric state, and we know that the ferrous states better absorb, so we actually do recommend have that kid take it with some orange juice to get the best bang for your buck.
00:13:30 Stephen Small
So to those folks who have written in asking if some fruit juices are actually good for certain meds, we say the verdict is.
00:13:39 Stephen Small
True, but with conditions also.
00:13:41 Stephen Small
Obviously it depends on the Med. Don't give juice with every Med as we're talking about in this episode.
00:13:46 Don Weinberger
Well, glad you're able to iron that one out, huh?
00:13:50 Stephen Small
Yes. OK. So.
00:13:53 Stephen Small
So I would say based on that, it turns out none of these juice claims are lemons.
00:13:58 Stephen Small
All have some truth to them, right?
00:14:01 Don Weinberger
Right. And they do bear fruit.
00:14:04 Don Weinberger
So it's a good idea to have these in mind when counselling patients and to address them if they can actually affect treatment.
00:14:11 Stephen Small
Nice. And with that, folks, thank you for joining us for our premiere rumor Versus Truth Podcast.
00:14:18 Don Weinberger
And a very special thanks to Gina for her amazing juice expertise.
00:14:24 Stephen Small
Absolutely. And read her excellent article about grapefruit juice and stat interactions in the January issue of pharmaceuticals letter and prescriber insights. And you know what?
00:14:36 Stephen Small
It actually also links to a great online chart about these drug interactions that I use all the time.
00:14:41 Don Weinberger
Yep. And so do I.
00:14:43 Don Weinberger
And if you aren't already, become a subscriber to our pharmacist letter and prescriber insight products to get the latest and greatest.
00:14:50 Don Weinberger
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00:14:57 Stephen Small
Also, folks, we need your help compiling more rumors and truths to analyze. So send us your ideas at trchealthcare.com/contact dash us or use the contact US link at the bottom of your TRC healthcare homepage.
00:15:13 Don Weinberger
We know you've got some great ideas for us to demystify and join us next time, where we'll solve some of the headaches around hangover remedies. Thanks for listening.
00:15:23 Narrator
And that’s a wrap on the premiere episode of Rumor vs Truth!
If you liked what you heard, be sure to follow, rate, and review this show wherever you get your podcasts and of course, check us out at TRChealthcare.com.
00:15:38 Narrator
Want to put faces to these voices? Catch the video version on YouTube - just search 'TRC Healthcare' or click the link in our show notes. While you're there, check out our other TRC podcasts like Medication Talk.
00:15:51 Narrator
Also in the show notes, we’ve linked a few of the resources mentioned today, like Gina’s article in the January 2025 issue of Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights, as well as the online chart on drug interactions that Steve pointed out.
00:16:07 Narrator
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00:16:16 Narrator
And if you're a student, good news—students can access a free version of Pharmacist’s Letter, we’ve linked to that directly in the show notes as well… Check it out!
00:16:25 Narrator
Thanks for joining us on Rumor vs Truth - your trusted source for facts... where we dissect the evidence behind risky rumors and reveal clinical truths.
See you next time!
