Statins and grapefruit juice?

Increase the risk of side effects from the statins Essentially, by drinking the grapefruit juice, Furanocoumarins in the juice inhibit the first pass metabolism of the statin in the liver. This leads to higher blood concentrations, and a higher risk for muscle aches and pain or even breakdown of muscle. For a detailed discussion on grapefruit interactions, follow the link below.

ACPE Program I.D. Number: 105-999-02-919-H01 Council of Ohio Colleges of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This program is acceptable for 2.0 hours of Continuing Education Credits (0.2 CEU) through 3/31/2006. Brought to you by an educational grant from Florida Department of Citrus.

Drug Interactions with Grapefruit Juice: An Evidence-Based Overview Sam Shimomura , PharmD, FASHP, CGP Sompon Wanwimolruk , PhD Jack J. Chen , PharmD, BCPS, CGP Behavioral Objectives After completing this continuing education article, the pharmacist should be able to: Identify the mechanism of grapefruit juice-drug interactions and drugs involved with significant grapefruit-drug interactions Describe potential effects of grapefruit juice-drug interactions. Discuss medications that may be affected and degree of risk associated with common interacting medications.

Identify effective alternative medications that do not interact (for patients who do not want to comply with dietary restrictions). Articulate the public health implications of media myths and inaccurate information surrounding this issue. Describe the pharmacist's role in communication the food-drug interaction issue to patients and physicians.

Effectively explain drug interaction risk factors and effective, alternative medications for patients. Table 2. Potential Interactions Between Grapefruit Juice and CYP3A4 Substrates Drug Class Drugs(s) with Significant Grapefruit Juice Interaction Drug(s) with Negligible Grapefruit Juice Interaction Findings with Significant Interaction Implications with Significant Interaction Anti-arrhythmics Amiodarone Increases AUC by 50% and peak plasma concentration by 84%.

Both PR and QRS intervals were not significantly altered and systolic arterial pressure decreased slightly.42 Watch for arrhythmias and toxicity. Quinidine Delays absorption of quinidine and inhibits the metabolism of active metabolite.43 Clinical significance is unknown. Anti-convulsant Carbamazepine Increases AUC, peak and trough concentrations by 40%.44 Watch for signs of toxicity such as dizziness, ataxia, drowsiness, nausea, vomiting, tremor, and agitation.

Monitor blood levels. Anti-depressant Sertraline Trazodone Nefazodone Clomipramine Increases plasma concentrations. Watch for increases in side effects.

Anti-histamine Fexofenadine Desloratadine May decrease oral absorption and blood levels by inhibiting the organic anion transporting polypeptide.24 Clinical significance is unknown. Anti-hypertensive Carvedilol Increases bio-availability of a single dose by 16%. Clinical significance is unknown Losartan May reduce the AUC of the major active metabolite.

May reduce effectivness of losartan but further studies are needed to determine significance. Anxiolytics & hypnotics Diazepam Midazolam Triazolam Buspirone Alprazolam Increased plasma concentrations. Watch for possible increase in sedation.

Caffeine Decreases caffeine clearance.45,46 Watch for possible increase in side effects such as nervousness or insomnia. Calcium channel blockers Felodipine Nicardipine Nifedipine Nimodipine Isaradipine Verapamil Amlodipine Diltiazem Increased plasma concentrations.47 Watch for toxicity, such as flushing, headache,t achycardia, and hypotension. Cortico-steroids Methylprednisolone, oral Prednisone Increased plasma concentrations.

Consumption of large amounts of grapefruit juice may increase the risk of adverse effects. Budesonide Increases ora absorption. L Watch for hypercorticism.

Estrogens Ethinyl estradiol Increased plasma concentration. Clinical significance is unknown. HMG-CoA reductase inhibitors Atorvastatin Lovastatin Simvastatin Fluvastatin Pravastatin Increased plasma concentrations.

Increased toxicity such as GI complaints and muscle pain. Immune modulators (immuno-suppressants) Cyclosporine Increased plasma concentrations of cyclosporine.48 Watch for signs of toxicity such as hepatotoxicity, renal toxicity, and increased immunosuppression. Tacrolimus Possible increases in plasma concentrations.

Watch for signs of toxicity such as nephrotoxicity, and increased immunosuppression. Macrolide antibiotics Erythromycin Increased plasma concentration. Clinical significance is unknown.

Protease inhibitors Ritonavir Nelfinavir Saquinavir Indinavir Amprenavir Increases plasma concentrations. Watch for possible increased side effects. Others Sildenafil Increased bioavailability.49 AUC = area under the curve; PR = pulse rate; GI = gastrointestinal.

Agrapefruit-drug interaction was discovered accidentally in 3/31/20061.1 In a double-blind, placebo-controlled study designed to assess the interaction of ethanol and the dihydropyridine calcium channel blocker, felodipine, the investigators used grapefruit juice to mask the taste of ethanol. Results suggested that the grapefruit juice in the vehicle may have resulted in elevated plasma concentrations of felodipine. A follow-up study confirmed that grapefruit juice increased the systemic bioavailability and augmented the hypotensive effects of the calcium channel blockers felodipine and nifedipine.2 Subsequently, studies have demonstrated significant interactions between grapefruit juice and certain drugs (Table).

The grapefruit (Citrus paradisi) grows in clusters (like grapes) on a tree. Grapefruit were initially discovered growing in the West Indies in the 1800s, and then brought to the United States where they are currently grown mainly in Florida, California, and Texas. Grapefruit are believed to have evolved from the pummelo, a citrus fruit from the Rutaceae family (orange family), through mutation or as a hybrid with the common orange.

The grapefruit is larger than an orange but smaller than most pummelos and can yield approximately 2/3 cup of juice. There are 2 major types of grapefruit: white and pink/ ruby red. As a widely available fruit source to help meet daily nutritional requirements, grapefruit and grapefruit juice are consumed by many individuals for the fiber, vitamin C, antioxidants, and phytochemicals.

For this reason, pharmacists need to understand grapefruitdrug interactions as well as common public misinformation, and communicate any potential interaction risks to patients. In the past decade, studies have shown that grapefruit juice can induce a several-fold increase in levels of particular drugs that can result in augmented therapeutic or toxic effects. The magnitude and the mechanism of this interaction appear to be the result of a significant inhibition of gut wall cytochrome P-450 3A4 (CYP3A4) isoenzymes and P-glycoprotein (P-gp).

This food-drug interaction is of clinical importance because grapefruit or grapefruit juice is consumed by approximately 21% of households in the United States,3 although grapefruit juice consumption in 2001-2002 declined 16% from the previous year. Are consumers being misled to avoid all grapefruit products for fear of potential adverse interactions with all medications? The purpose of this article is to examine the cause of this food-drug interaction; clarify the list of affected medications; and specify the pharmacist's role in counseling patients on options to avoid the possibility of a grapefruit-drug interaction.

Mechanism of Action Furanocoumarins have been demonstrated to inhibit the first-pass metabolism of certain drugs that are metabolized by CYP3A4. These compounds are found predominantly in the grapefruit flesh followed by the sac, peel, and seed.4 The main mechanism of the grapefruit-drug interaction (Figure) appears to result from inhibition of CYP3A4 in the gut wall, and it is most important for drugs with low oral bioavailability (ie, drugs with high first-pass metabolism).5 The onset of the interaction can occur within 30 minutes following intake of a single glass of grapefruit juice, and the inhibition can last up to 3 days following the last administration of grapefruit juice.6 The magnitude of inhibition of CYP isoenzymes by grapefruit components appears to be greatest for CYP3A4 and less significant for other CYP isoforms (eg, 1A2, 2C9, and 2C19).7 Additionally, the interaction appears to affect CYP3A4 in the gut wall to a much greater extent than in the liver.5 Originally, naringin was thought to be the main component responsible for grapefruit-drug interactions. However, studies have shown naringin to be a weak inhibitor of CYP3A4.8,9 It was also demonstrated that the administration of isolated naringin to humans, in quantities comparable to those found in grapefruit juice, did not cause the same degree of inhibition as grapefruit juice.In addition to flavonoids, researchers have also focused on furanocoumarins found in grapefruit juice as CYP3A4 inhibitors.10,11 Furanocoumarins in grapefruit juice exhibit a mechanism-based inhibition in which a reactive metabolite is formed and covalently binds to the CYP3A4 isoenzyme, resulting in inhibition.

The furanocoumarins are divided into 6 components: 6',7'-dihydroxybergamottin (DHB), GF-I-1, bergamottin (GF-I-2), GF-I-4, GF-I-5 (bergamottin-6',7'-epoxide), and GFI- 3/31/20060 Significant inhibition of CYP3A4 isoenzyme activity is exhibited by DHB, GF-I-1, and GF-I-4 with minimal activity exhibited by bergamottin (a presumed precursor of GF-I-1 and GF-I-4 and a known ingredient of grapefruit essential oil).13 Orange juice has no CYP3A4-inhibiting effects. When orange juice was spiked with a synthetic DHB, however, no significant differences between the degree of inhibition produced by either of the 2 citrus fruits was observed. Therefore, the DHB component in grapefruit appears to be another potent inhibitor of CYP3A4 and is most likely primarily responsible for the interaction.

To thoroughly assess the clinical significance of grapefruit-drug interactions, the type and amount of grapefruit juice must be considered. Consumption of a single 8-oz glass of regular-strength grapefruit juice is sufficient to inhibit CYP3A4. The magnitude of interaction may vary depending on the extent of intestinal CYP3A4 expression in an individual patient.

This variation between individuals may be significant and is difficult to predict. The grapefruit-drug interaction appears to affect patients with high quantities of small bowel CYP3A4 isoenzymes.14 Based on evidence from in vitro, in vivo, and clinical studies, it is now recognized that most drugs do not interact with grapefruit juice. Grapefruitdrug interactions appear to occur only under well-defined circumstances.

First, the drug substrate must be predominantly metabolized by CYP3A4. Second, the drug substrate must undergo extensive first-pass metabolism (ie, drugs with low oral bioavailability). Knowledge of these 2 factors will allow pharmacists to predict whether a medication is likely to interact with grapefruit juice.

For example, felodipine has a low oral bioavailability of 15% and is significantly affected by grapefruit juice; whereas amlodipine has a high oral bioavailability of 75% and does not interact with grapefruit juice.15 Other examples are verapamil and quinine. Grapefruit juice significantly increased plasma concentrations of verapamil (oral bioavailability of 20%) and had no significant effect on the pharmacokinetics of quinine (oral bioavailability of 80%).16,17 The CYP3A4 isoenzyme, which is found in the intestine and liver, accounts for about 40% to 60% of all CYP450 isoenzymes (although it is important to note that grapefruit inhibits CYP450 in the gastrointestinal tract, not the liver) and is involved in the majority of significant CYP450-mediated drug interactions. Inhibition of the CYP3A4 isoenzyme, either reversible or irreversible, will result in a reduced metabolism and metabolic clearance of CYP3A4 substrates.

Inhibition of the CYP system occurs through 2 mechanisms. The first and most common mechanism is known as competitive inhibition and results from the competition between the inhibitor and substrate for the same CYP isoenzyme required for substrate metabolism and elimination. The effects of competitive inhibition can be observed after administration of the first dose of the inhibitor.

The second mechanism is known as mechanism-based inhibition and occurs with grapefruit juice. The most potent grapefruit components causing a mechanism-based inactivation of CYP3A4 are furanocoumarins, which bind irreversibly to CYP3A4 and permanently inactivate the isoenzyme.18 The duration of mechanismbased inhibition may be longer than competitive inhibition because new CYP3A4 isoenzymes must be synthesized for activity to be restored. Complete recovery of the CYP3A4 may take 48 to 72 hours after the last exposure to grapefruit juice,19 which explains why the effects can last for at least 72 hours after drinking grapefruit juice.20 Most important, because of mechanism-based inhibition, separating the administration of grapefruit juice and substrate drug by a few hours does not minimize grapefruitdrug interactions.

Pharmacists should advise patients to avoid grapefruit entirely if they are taking medications known to significantly interact with grapefruit juice. In addition to the effect on CYP3A4, grapefruit juice may also inhibit the drug transporters P-gp and organic anion transporting peptide (OATP). P-gp is an efflux membrane transporter pump belonging to the adenosine triphosphate-binding cassette family of proteins.23/31/20061 As with CYP3A4, P-gp is found in high concentrations within intestinal enterocytes, the primary site of oral drug absorption.

The role of P-gp is to actively secrete absorbed drugs back into the intestinal lumen. After uptake by the enterocyte, the drugs are either metabolized by CYP3A4 or pumped back out (effluxed) into the lumen by the P-gp transporter. Therefore, inhibition of CYP3A4 or Pgp will increase blood levels of the drug substrate.

The OATP is a transmembrane sodium- and ATP-independent transporter present in the intestinal mucosa and promotes influx (uptake) of drugs into the enterocytes. Some evidence suggests that active grapefruit components may inhibit intestinal P-gp.24 Preliminary evidence also suggests that grapefruit components inhibit OATP.25 Pharmacists should be aware that grapefruit juice inhibition of OATP results in reduced blood levels of the drug substrate. This is in contrast to inhibition of CYP3A4 or P-gp, which will result in increased levels of the drug substrate.

The effect of grapefruit components on P-gp and OATP are still under unclear, however, and additional research is needed. Grapefruit-Drug Interactions: Increased Blood Levels Benzodiazepines Many benzodiazepines, including midazolam and triazolam, are substrates of CYP3A4 and are metabolized by hepatic and intestinal CYP3A4. Coadministration with grapefruit juice did not alter the pharmacokinetics and pharmacodynamics of intravenous midazolam.

After an oral dose of midazolam, however, grapefruit juice significantly increased the peak plasma concentration by 56% and the area under the curve (AUC) by 52%.26 These changes were associated with significant alterations in the pharmacodynamic effects of midazolam, such as delay of the reaction time. Additionally, grapefruit juice increased the AUC (by 50%) and the peak plasma concentration (by 30%) of triazolam in healthy volunteers and was associated with increased drowsiness.27 Caution must be taken when giving oral midazolam, particularly in patients with other causes for increases in midazolam bioavailability, such as advanced age, liver cirrhosis, and coadministration of other CYP3A4 inhibitors. All of these conditions may potentiate the effects of grapefruit juice.

Certain Immunosuppressants Cyclosporine is an immunosuppressant used widely in solid organ and bone marrow transplantation as well as in the treatment of psoriasis. Oral cyclosporine formulations (ie, oil/water and microemulsion) have been well documented to interact with grapefruit juice through inhibition of CYP3A4 and P-gp. However, intravenous cyclosporine formulations do not interact.

In one study, the mean absolute oral bioavailability of cyclosporine increased by 62% with grapefruit juice administration, but there was no significant effect with intravenous cyclosporine.28 The magnitude of pharmacokinetic changes associated with the grapefruitcyclosporine interaction is variable and unpredictable within individuals and should not be used as a strategy to reduce cyclosporine dosages and save on drug costs. Tacrolimus is an immunosuppressant metabolized by CYP3A4. Because the bioavailability of tacrolimus is doubled by ketoconazole, a potent CYP3A4 inhibitor, an interaction with grapefruit juice may also occur.

Until more data are available, concurrent administration of tacrolimus and grapefruit juice should be avoided.29 Certain Calcium Channel Blockers The dihydropyridine calcium channel blockers, felodipine, nifedipine, nisoldipine, and nitrendipine, are substrates of CYP3A4 and undergo extensive first-pass metabolism by hepatic and intestinal CYP3A3/31/20060,31 When grapefruit juice is administered in combination with oral felodipine, concentrations of felodipine increase significantly compared with felodipine alone.32 When felodipine was administered intravenously with oral grapefruit juice, the plasma concentration of felodipine was not significantly altered. Clinical data show that the ingestion of 1 glass of grapefruit juice can alter felodipine pharmacokinetics for up to 3 days.33 Thus, when dosing a patient who has been on grapefruit juice, a 3-day washout period should occur before initiating felodipine. Verapamil, a nondihydropyridine calcium channel blocker, is commonly used for the treatment of cardiovascular conditions and migraines.

In healthy volunteers, administration of verapamil 120 mg twice daily for 3 days plus grapefruit juice 200 mL twice daily for 5 days resulted in a moderate but statistically significant increase in verapamil concentrations. In this study group of healthy volunteers, changes in heart rate or blood pressure were not statistically significant. Clinical effects in more fragile patients may be more significant, however, and the combination of grapefruit juice and verapamil should be avoided.34 HMG-CoA Reductase Inhibitors (Statins) A study showed that 2 days of pretreatment with 200 mL doublestrength grapefruit juice 3 times a day, as compared with water, prior to administration of lovastatin 80 mg increased the peak concentrations of lovastatin and the metabolite, lovastatin acid, by 12- and 4-fold, respectively.35 The AUC for lovastatin and the metabolite also increased significantly, 15- and 5-fold, respectively.

The half-life remained unchanged. In another study, 8 oz (240 mL) of regular- strength grapefruit juice was administered in the morning, 12 hours after pretreatment with lovastatin 40 mg once daily for 3 days. Plasma concentrations of lovastatin increased by approximately 30%.36 The inconsistent results of these 2 studies are most likely due to differences in lovastatin dosage, pretreatment regimens, and grapefruit juice potency.

Administration of a single dose of simvastatin 60 mg after 2 days of pretreatment with 200 mL of doublestrength grapefruit juice administered 3 times daily resulted in a 9- and 7-fold increase in serum concentrations for simvastatin and the metabolite, simvastatin acid.37 The AUC was increased 16- and 7-fold for simvastatin and simvastatin acid, respectively. Pretreatment with 200 mL doublestrength grapefruit juice 3 times a day for 2 days resulted a 2.5-fold increase in the AUC of atorvastatin 40 mg.38 In addition, the half-life of atorvastatin was increased from 7.8 hours to 13.3 hours. The AUC of atorvastatin's active metabolites, atorvastatin lactone and 2-hydroxyatorvastatin, are increased approximately 1.3-fold.

In a similar study, grapefruit juice had no effect on pravastatin (40 mg) serum concentration or AUC.39 The results of these studies suggest that concomitant administration of grapefruit juice with atorvastatin, lovastatin, and simvastatin should be avoided. Potentially serious adverse reactions due to elevated levels of statins and metabolites include myalgia and rhabdomyolysis. If this combination cannot be avoided, pharmacists should educate patients on the symptoms of statin-induced myalgia and rhabdomyolysis (eg, muscle aches, back pain).

A safer alternative would be pravastatin. Fluvastatin is not metabolized by CYP3A4 and should not interact, although it has yet to be studied with grapefruit juice. Grapefruit-Drug Interactions: Reduced Blood Levels Fexofenadine Studies also demonstrate that grapefruit juice can reduce blood levels of drugs and possible reduce efficacy.

Fexofenadine is transported into the systemic circulation by OATP. Because grapefruit juice inhibits OATP, blood levels of fexofenadine are reduced. OTC Medications Research has yet to uncover clinically significant interactions between grapefruit juice and OTC medications.

Caffeine, dextromethorphan, chlorpheniramine, and loratadine, however, may interact to some degree, but because of the wide therapeutic index of these drugs, occasional use of these OTC medications in standard doses with concurrent grapefruit ingestion is not expected to result in significant adverse effects. Caution may be warranted, however, in the elderly and in individuals who may be taking other prescription or nonprescription CYP3A4 inhibitors (eg, cimetidine, clarithromycin, erythromycin, fluvoxamine, itraconazole, ketoconazole, nefazadone, and protease inhibitors such as indinavir, nelfinavir, and ritonavir). Additionally, dietary supplements or botanical products such as St. John's wort may also inhibit CYP3A4 and may result in additive enzyme inhibition with grapefruit.

Public Misinformation Although the grapefruit-drug interaction was first reported in the scientific literature as early as the late 1980s, the significance of this interac- tion was not rapidly recognized by the medical community, and dissemination of accurate information to the public was also inconsistent.40 At times, the public received information that was sensationalized and inaccurate. This may have contributed to confusion among patients and pharmacists over the issue of grapefruitdrug interactions. Many patients believed that all drugs interacted with grapefruit juice and stopped drinking grapefruit juice altogether.

Other articles incorrectly reported that the interaction could be prevented by separating the drug and the grapefruit juice by 2 hours. A television news story even encouraged patients to drink grapefruit juice to get more out of their medications and save money.41 Role of the Pharmacist in Communication The Gallup organization has consistently rated pharmacists at the top or near the top of the most trusted and respected professions. Patients rely on the pharmacist for convenient advice on health issues.

A survey of 100 pharmacists nationwide by the Florida Department of Citrus in December 2001 found that nearly 66% of pharmacists had seen an increase in the number of patients seeking information about grapefruit juice-drug interactions, but that only 50% believed they had enough specific information about grapefruit juice interactions. Pharmacists play an important role in potential grapefruit-drug interaction situations. Patients need accurate, specific information about the grapefruit juice-drug interaction.

When educating a patient regarding a potential grapefruit-drug interaction (Table), ask about grapefruit or grapefruit juice consumption. Many fruit juice blends also contain significant amounts of grapefruit juice. Remind patients that most citrus juices such as sweet orange, lemon, citron, and tangerine are considered safe.

Sour oranges such as Seville oranges, however, may have an effect similar to grapefruit juice, but these fruits are not used in commercial orange juice production nor are they commonly sold in the United States. Lime juice may also interact.In situations where a patient is taking a medication that interacts with grapefruit juice and does not wish to stop consuming it, the pharmacist might suggest other medication options. Pharmacists can often predict if a new drug might be a candidate for a significant interaction with grapefruit or its juice by looking at these characteristics: Is it metabolized by intestinal CYP3A4?

Is it given orally? Does it have a low bioavailability? Does it have a narrow therapeutic index?

The following key messages should be communicated to patients: Most medications do not interact with grapefruit juice, but if you consume grapefruit or grapefruit juice let your physician or pharmacist know, especially when beginning a new prescription. The effects of OTC products and herbal medications, although believed to be safe based on the current literature, should still be monitored. Alternative medications that do not interact with grapefruit may be available if you do not want to stop drinking grapefruit juice or eating grapefruit.

The Future of Grapefruit-Drug Interactions Many researchers are studying drug interactions with grapefruit to identify the drugs that do and do not interact with grapefruit as well to more clearly elucidate the role of P-gp and OATP in the interaction.In addition, more studies are needed to clarify interactions involving OTC medications and herbal medications. Acknowledgments The authors would like to acknowledge and thank the following senior pharmacy students at the Western University of Health Sciences College of Pharmacy for their contribution to this article: Joyce Li, George Tran, and Catherine Youssefyeh. Professor of Pharmacy Practice, Associate Dean, College of Pharmacy Western University of Health Sciences Associate Professor Pharmaceutical Sciences College of Pharmacy, Western University of Health Sciences Assistant Professor Pharmacy Practice College of Pharmacy, Western University of Health Sciences Back to Top Sources: https://secure.pharmacytimes.Com/lessons/200303-02.

Asp .

Increased risk of side effects Statins are metabolized by enzymes called Cyp 450s. Grapefruit juice inhibits these enzymes so that the statins don't get metabolized to the extent they normally do. This means the blood levels of the statin increases increasing the risk of side effect because the levels may become to high.

The specific side effect they are worried about is myotoxicity (the muscles in your body start to breakdown) which is a fairly serious side effect. Sources: Pharmacy education .

Depends on the specific drug - blocks liver metabolism of the drug The best advice is to ask your Dr. or pharmacist, and read labels carefully. - Per medicalnewstoday.com/articles/15803.php The UK Medicines and Healthcare Products Regulatory Agency (MHRA) says that certain cholesterol lowering drugs (statins), when taken with grapefruit juice can raise the patient's risk of muscle toxicity. The MHRA said this was especially so with Zocor (simvastatin), of Merck & Co and Lipitor, of Pfizer.

There is a liver enzyme which is crucial for drug metabolism. Grapefruit juice suppresses the activity of this enzyme. If you drink grapefruit juice regularly, there is a risk that you will have raised levels of the statin in your bloodstream.

The MHRA said there is no significant risk with other statins such as Lescol (Novartis), Pravachol (Bristol Myers Squibb) and Crestor.(AstrraZeneca). - per CBS news, via WebMD: http://www.cbsnews.com/stories/2005/01/20/health/webmd/main668105.shtmlDrugs That Interact With Grapefruit Juice Here are some drugs that interact with grapefruit juice. Check with your doctor or pharmacist if you're concerned about any of your medications.

Anxiety: Xanax, Buspar, Versed, Halcion Depression: Luvox, Zoloft Allergies: Allegra Abnormal heart rhythm: Cordarone, quinidine Heart disease/stroke/blood clots: Coumadin Epilepsy: Tegretol Cancer: Cyclophosphamide, etoposide, ifosfamide, tamoxifen, vinblastine, vincristine Cough: Dextromethorphan (found in many over-the-counter cold medicines) HIV: Agenerase, Crixivan, Viracept, Norvir, Fortovase Prostate enlargement: Proscar Heart disease/gh blood pressure: Coreg, Cardizem, Plendil, Cardene, Adalat, Procardia, Nimotop, Sular, Covera, Calan, Verelan Erectile dysfunction: Viagra, Cialis Asthma/Emphysema: Theophylline gh cholesterol: Lipitor, Lescol, Mevacor, Zocor Pain: Alfenta, Duragesic, Actiq, Sufenta Infection: Biaxin, Sporanox, erythromycin, troleandomycinPatients should check with their doctors about specific interactions between grapefruit juice and medication. Sources: medicalnewstoday.com/articles/15803.php .

Not recommended Grapefruit juice affects the metabolism of statin medications in the liver and will not increase the effectiveness of the medication, but may worsen the side effects, especially mypathy (muscle pain-usually in the legs). It is best to have grapefruit juice 2 hours before or 4 hours after taking a statin.

1 I can't tell you exactly what happens, but you're not supposed to have grapefruit with most (or all) statins. This user has been banned from Askville.

1 I can't tell you exactly what happens, but you're not supposed to have grapefruit with most (or all) statins.

I can't tell you exactly what happens, but you're not supposed to have grapefruit with most (or all) statins.

Does cooking grapefruit juice make it ok to take with medicine.

Is boiled grapefruit juice ok to take with medicine.

I cant really gove you an answer,but what I can give you is a way to a solution, that is you have to find the anglde that you relate to or peaks your interest. A good paper is one that people get drawn into because it reaches them ln some way.As for me WW11 to me, I think of the holocaust and the effect it had on the survivors, their families and those who stood by and did nothing until it was too late.