INTERACTIONS of drugs/supplements in treating Lyme

Discussion in 'Lyme Disease Archives' started by victoria, Jun 17, 2006.

  1. victoria

    victoria New Member

    Below is a part of the article, you can find entire article by googling the title:


    Leo Galland M.D.

    Lyme Times, published by the California Lyme Disease Association (CALDA)

    Interactions between prescription or over the counter drugs and nutritional supplements are common and often not well known.

    People with Lyme and related diseases are usually administered prolonged therapy with antibiotics, often combined with Prilosec or other proton pump inhibitors (drugs that greatly reduce stomach acid), sometimes in conjunction with Plaquenyl (an immune modulator) or anti-parasitic drugs for treatment of babesiosis.

    Some potential interactions (negative and positive) between these drugs and dietary supplements are described below. Information on drug/food interactions is usually available from the pharmacist and included in the patient-package insert. This should be checked for each individual drug being taken, because the dosage form (sustained-release vs. regular, for example) may influence the effect of food on drug absorption.

    Patients with chronic tick-borne infections may also be taking antidepressants and pain relievers, each of which may have its own interactions with nutritional supplements and nutritional status.

    Drugs may interact with food or supplements through the following mechanisms:

    (1) The food or supplements may interfere with drug absorption. This is especially important for tetracycline or quinolone antibiotics. {Although quinolones like Levaquin are not used for Lyme disease, they are the primary drugs for treatment of bartonellosis, a common co-infection). Both groups of antibiotics form insoluble complexes with minerals, especially calcium, magnesium or iron. This process, called chelation, inhibits absorption of both the antibiotic and the mineral.

    Not only are most tetracyclines (with the sole exception of doxycycline) and all quinolones better absorbed away from food (especially mineral-rich foods like meat and dairy products), they must be taken several hours apart from any nutritional supplements containing minerals. Two hours of separation may not be enough. Several herbs, including fennel, dandelion, and Sanguisorba, have a high enough mineral content that their consumption has been shown to interfere with quinolone absorption.

    Penicillins may have their oral absorption impaired by fiber or by food, although this is more likely for penicillin V and ampicillin that for amoxacillin. Food causes the drug to be retained in the stomach, where the presence of acid causes the drug to decompose. Psyllium has been shown to bind oral penicillin, decreasing its absorption.

    (2) The drug may increase the requirement for certain nutrients, because it causes depletion of the nutrient from the body. The normal gastrointestinal bacterial flora synthesize B vitamins, biotin and vitamin K, which are absorbed and utilized by humans.

    Depletion of these bacteria by prolonged antibiotic therapy may produce vitamin deficits. Bleeding caused by vitamin K deficiency has occurred as a result of intravenous therapy with cephalosporin antibiotics[1], a group that includes Rocephin and Claforan. High dose penicillin therapy causes increased excretion of potassium by the kidneys[2].

    When combined with antibiotic-induced diarrhea or poor appetite, this effect may cause potassium deficiency, with fatigue and muscle weakness as primary symptoms. Proton pump inhibitors like Prilosec, used to enhance antibiotic absorption and cellular penetration, decrease formation of stomach acid, permitting overgrowth of bacteria and/or yeast in the stomach and upper gastrointestinal tract.

    Microbial overgrowth may be associated with gastrointestinal symptoms like diarrhea and bloating[3] and may cause malabsorption of nutrients. Prolonged use of PPIs has been associated with decreased absorption of vitamin B12, zinc, and carotene and may create a need for supplementation[4].

    (3) Drugs, supplements and food may interact by inhibition or stimulation of enzymes involved in drug transport or metabolism.

    The cytochrome P450 (CYP) system is extensively involved in drug metabolism and may be strongly inhibited or stimulated by drugs, foods or dietary supplements. CYP enzymes are most active in the liver, intestines, lungs and kidneys. Humans have over 20 different CYP enzymes, all of which contain iron and which all use oxygen to change the structure and function of the drugs they metabolize. ...

    Another important aspect of drug metabolism is transport into and out of cells. ...grapefruit juice or other natural substances can increase absorption of drugs that are P-gp or CYP3A4 substrates, raising their concentration in blood. This effect is only important for drugs that are slowly absorbed in the intestine to begin with. Drugs that pass through the intestinal lining rapidly are absorbed too quickly for inhibition of CYP or P-gp enzymes in the intestine to affect drugs levels.

    St. John's wort is one of the few products that stimulate intestinal P-gp and CYP3A4. Taking St. John’s wort can decrease the plasma concentration of those same drugs and underlies many of the adverse drug interactions reported for this herb.

    Some important interaction of drugs used in treating tick-borne diseases and the CYP system are listed below:

    CYP2C9 is increased by rifampin (an antibiotic sometimes used to treat Bartonella) and inhibited by fluconazole (Diflucan, an anti-fungal).

    CYP2C19 is increased by rifampin and artemisin (a derivative of the herb Artemisia annua, a natural anti-malarial herb that may be used in the treatment of Babesiosis). CYP2C19 is decreased by Prilosec and ketoconazole (Nizoral, an anti-fungal).

    CYP3A4 is increased by St. John's wort and rifampin and inhibited by grapefruit juice, Seville orange juice, the anti-fungal drugs ketoconazole (Nizoral) and itraconazole (Sporanox), and the macrolide antibiotics azithromycin (Zithromax), clarithromycin (Biaxin) and telithromycin (Ketek).

    The effect of grapefruit juice occurs only in the intestines, not in the liver, so it can--at high levels of consumption--increase absorption of some drugs without affecting their internal metabolism.

    Artemisinin is metabolized by intestinal CYP3A4, and its absorption appears to be enhanced by grapefruit juice[5].

    The herb Echinacea, used for immune stimulation, inhibits intestinal CYP3A4 but stimulates the liver's CYP3A4, so it may increase or decrease the levels of a co-administered drug, depending upon the drug's rate of absorption and the extent to which it is metabolized by CYP3A4.

    Milk thistle, an herb used to support liver function, contains a group of bioflavonoids called silymarin. Silymarin may inhibit intestinal P-gp and liver CYP3A4. Surprisingly, concomitant administration of milk thistle significantly decreased the absorption of metronidazole (a drug used to treat the spore form of Borrelia).[6] This interaction could not have been predicted from knowledge of the herb's effects on drug metabolizing enzymes.

    Moreover, vitamin C (500 mg/day) and vitamin E (400 units/day) decreased the effectiveness of metronidazole (flagyl) in treating H. pylori infection of the stomach.[7] The mechanism of this interaction is unknown but suggests that anti-oxidants should not be used with metronidazole therapy.

    Quercetin, a bioflavonoid used as an anti-oxidant and for relief of allergic symptoms, competes with quinolone antibiotics for binding sites on bacteria. No interaction between quercetin and antibiotics has yet been demonstrated outside a test tube, but it would be prudent for people taking quinolone antibiotics to refrain from the use of quercetin and perhaps other bioflavonoids.

    Beneficial effects of dietary supplements for people taking antibiotics have been described. The most consistent benefits have been demonstrated for probiotics (living organisms) that can counter the gastrointestinal side effects of antibiotics.

    The best studied are Saccharomyces boulardii (a yeast, dubbed "yeast against yeast" in France)[8], Lactobacillus rhamnosis GG[9], Lactobacillus plantarum and Lactobacillus sporogenes[10].

    Proteases are enzymes that digest protein. When taken by mouth on an empty stomach some of the preparation is absorbed intact and may be active in the body.

    Oral proteases have been shown to relieve pain and inflammation in patients with arthritis[11], may break down circulating complexes of antigen and antibody (these have been described in so-called "post-Lyme syndrome") and may breakdown blood clots that form as a result of inflammation.

    Although research on proteases as adjuncts to antibiotic therapy is minimal, a study done in animals found that bromelain (a protease-containing extract of pineapple stem), increased penetration of tetracyclines into the tissues[12].

    OK don't ask me any specific questions lol, cuz what I look for are specific directions/interactions between things...

    but if anyone knows where to buy those specific probiotics, let me know?


  2. hopeful4

    hopeful4 New Member


    I'm going to print this out and read it. Thanks for the post. You are a wealth of info and support.

  3. jarjar

    jarjar New Member

    Found out a few things I didn't know...thanks for going to the trouble!

  4. victoria

    victoria New Member

    We have our son taking a lot of supplements as well, so I was trying to doublecheck things for him...

    Supplements have helped him; altho I'm not sure he has fully understood the importance of probiotics quite yet.

    Bromelain was a standby for me a few years ago when I had a bone spur in my foot - the above explains now a bit further to me why it worked so well. I was taking about 2500 mg twice per day, and the spur actually disappeared - the bromelain had already been known to stop pain from inflammation even after working out. (The original study was done on boxers!)

    Just wondering, has anyone found those probiotics mentioned in the article above?

  5. minimonkey

    minimonkey New Member

    Thanks so much for posting this!

    One thing that isn't mentioned here, but that is well documented...

    Milk Thistle interferes with Mepron. It decreases the amount of Mepron/Malarone in the blood stream.

    This is tricky, because when taking so many high-dose abx and other drugs (like Mepron), the liver gets really taxed over time.

    I, personally, have decided to go ahead and take my milk thistle and other liver-support --- I may need to stay on the mepron longer, but so be it. I only have ONE liver, and I can always get more mepron. I do take it hours away from my doses of Mepron, but that only minimizes the effect -- it doesn't stop it entirely.

    I'm taking Ketek, which is particularly hard on the liver, so I am being extra-cautious to protect my liver as much as I can.
  6. victoria

    victoria New Member

    Thanks Texaschaos, I will follow up on those links!

    Zoe - I hope you are getting regular liver tests? I know they do regular ones for my son, it does help to keep tabs...

    all the best,

  7. minimonkey

    minimonkey New Member

    Oh, yes -- I get a liver test every month. My enzymes have risen a little bit, but not out of the safe range at all.

    I'm taking a bunch of things that place a major stress on the liver: ketek (big offender!), diflucan, mepron, occasional vicodin -- plus the bicillin injections, which aren't as bad, but all abx stress the liver to some degree.

    I am taking a lot of liver support, too -- that gets tricky, because milk thistle and co-Q 10 can interfere with the absorption of mepron somewhat -- but I'd rather take the mepron for longer and have a good liver on the other end of things. I do take my supps hours away from my other meds, but I think they still cross-react to some degree. I also take a lot of stuff for detox (burbur, sarsparilla, red root, chlorella, N-Acetyl Cysteine, Vitamin b6, etc.) which help to decrease the overall toxic strain on the body -- N-Acetyl Cysteine is a great liver protector, too. If my enzymes start to get scary, I'll talk to my NP about other options, for sure.

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