Depletions
Depletion happens when a drug “depletes” or causes the body to lose a nutrient. The drug might also interfere with the nutrient’s absorption.

A good example of a drug that depletes nutrients from the body is the diuretic furosemide. Furosemide causes the body to lose potassium, so people taking furosemide might need to supplement with potassium to avoid unwanted problems such as muscle cramps, fatigue, or heart-rhythm disturbances.

Interactions
Interactions happen when a nutrient affects the way a drug works, or when a drug affects the way a nutrient works. Interactions can be beneficial or harmful.

An example of a good result of an interaction might be when a person taking the drug fluoxetine (Prozac) also takes the nutrient folic acid. This combination might increase the drug’s effectiveness.

An example of a bad result of an interaction might be a person taking the herb St. John’s wort while taking the drug digoxin (Lanoxin). In this situation, the herb might reduce the absorption of the drug, which would result in lower-than-necessary blood levels of the drug.

Using Medicines with Vitamins and Herbs (Rx Answers/Medicine Answers)
Healthnotes provides depletion and interaction information for drugs, nutritional supplements, herbs, and foods. All medications are indexed alphabetically both by their generic and brand names.

Within each drug article you will find a summary listing the interacting supplements, herbs, and foods in one or more of the following six categories:

May Be Beneficial

Depletion or interference—The medication may deplete or interfere with the absorption or function of the nutrient. Taking these nutrients may help replenish them.
Side effect reduction/prevention—Taking these supplements may help reduce the likelihood and/or severity of a potential side effect caused by the medication.
Supportive interaction—Taking these supplements may support or otherwise help your medication work better.
Avoid

Adverse interaction—Avoid these supplements when taking this medication because taking them together may cause undesirable or dangerous results.
Reduced drug absorption/bioavailability—Avoid these supplements when taking this medication since the supplement may decrease the absorption and/or activity of the medication in the body.
Explanation Required

Other—Before taking any of these supplements or eating any of these foods with your medication, read the drug article in full for details.

Frequently Asked Questions
Why do you sometimes list a supplement as both beneficial and something to avoid for the same drug?
When a medication depletes the body of a nutrient, it may be beneficial to take more of that nutrient to compensate; however, it might also be necessary to avoid taking the nutritional supplement at the same time as the drug because taking them together might reduce drug absorption.

For example, calcium is listed as both beneficial and as something to avoid when taking thyroid medication. Taking extra calcium might be necessary to replace the calcium that is depleted by thyroid hormone, but it should not be taken at the same time as thyroid hormone because calcium might reduce absorption of the drug.

How do I know if my drug is causing a depletion or interaction?
Usually a person does not know that a drug is depleting a nutrient until the body shows symptoms of deficiency. In some cases, your healthcare provider might run blood tests to check whether nutrient levels are low. For example, individuals taking the diuretic furosemide should have potassium blood levels monitored regularly to detect depletion.

You might notice a bad interaction if your drug stops working as effectively or if you develop unwanted symptoms when you begin taking a new nutrient or add a new food to your diet. Similarly, you might notice a beneficial interaction if your drug starts working better after adding a new food or nutrient.

As natural substances, are herbs and vitamins safer than drugs?
Herbs and vitamins are not necessarily safer just because they are natural. Though herbs and vitamins are generally safer than drugs, some might produce unwanted side effects when a person takes too much. And if you are taking medications, you should always check with your doctor or pharmacist before taking new herbs or nutritional supplements.

When nutrients are depleted, are supplements the only way to replace them?
Though supplements are more commonly used than foods to replace depleted nutrients, certain foods may also work. For example, people who need to replace potassium might choose to eat bananas or other fruit rather than take supplements.




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Copyright © 2007 Healthnotes, Inc. All rights reserved. www.healthnotes.com

Learn more about Healthnotes, the company.

Learn more about the authors of Healthnotes.

The information presented in Healthnotes is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications. Information expires September 2008.

About sertraline
Sertraline is a member of the selective serotonin reuptake inhibitor (SSRI) family of drugs used to treat people with depression.

Helpful Products
Try these helpful products which may be beneficial if taken with this medicine

Chromium
Taking 200 to 400 mcg of chromium each day might enhance the antidepressant effect in some people taking sertraline for depression
Ginkgo
Some individuals taking sertraline might develop unwanted sexual side effects; taking 240 mg per day of the herb Ginkgo biloba might prevent this complication
These recommendations are not comprehensive and are not intended to replace the advice of your doctor or pharmacist. Continue reading the full article for more information on interactions with vitamins, herbs, and foods.

Summary of Interactions with Vitamins, Herbs, and Foods
In some cases, an herb or supplement may appear in more than one category, which may seem contradictory. For clarification, read the full article for details about the summarized interactions.

May Be Beneficial: Depletion or interference—The medication may deplete or interfere with the absorption or function of the nutrient. Taking these nutrients may help replenish them. Sodium

May Be Beneficial: Side effect reduction/prevention—Taking these supplements may help reduce the likelihood and/or severity of a potential side effect caused by the medication. Ginkgo biloba*

May Be Beneficial: Supportive interaction—Taking these supplements may support or otherwise help your medication work better. Chromium*

Avoid: Adverse interaction—Avoid these supplements when taking this medication because taking them together may cause undesirable or dangerous results. 5-Hydroxytryptophan (5-HTP)

L-tryptophan

St. John’s wort*

Reduced drug absorption/bioavailability None known


An asterisk (*) next to an item in the summary indicates that the interaction is supported only by weak, fragmentary, and/or contradictory scientific evidence.

Interactions with Dietary Supplements
Chromium
There have been five case reports of chromium supplementation (200–400 mcg per day) significantly improving mood in people with a type of depression called dysthymic disorder who were also taking sertraline.1 These case reports, while clearly limited and preliminary in scope, warrant a controlled trial to better understand the benefits, if any, of chromium supplementation in people taking this drug.

5-Hydroxytryptophan (5-HTP) and L-tryptophan
Sertraline increases serotonin activity in the brain. 5-HTP and L-tryptophan are converted to serotonin in the brain, and taking either of these compounds with sertraline may increase sertraline-induced side effects.

In one report, dietary supplements of L-tryptophan (available only by prescriptions from special compounding pharmacists) taken with paroxetine (a drug similar to sertraline) caused headache, sweating, dizziness, agitation, restlessness, nausea, vomiting, and other symptoms.2 On the other hand, the combination of 45 mg DL-tryptophan (a synthetic variation of L-tryptophan) per pound of body weight (a relatively high dose) with zimelidine, a drug with a similar action to sertraline, did not cause these side effects in another trial.3 Some doctors have used small amounts of L-tryptophan in combination with SSRIs, to increase the effectiveness of the latter. However, because of the potential for side effects, 5-HTP and L-tryptophan should never be taken in combination with sertraline or other SSRIs, unless the combination is being closely monitored by a doctor. Foods rich in L-tryptophan do not appear to interact with sertraline or other SSRIs.

Sodium
SSRI drugs, including sertraline, have been reported to cause sodium depletion.4 5 6 The risk for SSRI-induced sodium depletion appears to be increased during the first few weeks of treatment in women, the elderly, and patients also using diuretics. Doctors prescribing SSRI drugs, including sertraline, should monitor their patients for signs of sodium depletion.

Interactions with Herbs
Ginkgo biloba
In three men and two women treated with fluoxetine or sertraline (SSRI drugs closely related to paroxetine) for depression who experienced sexual dysfunction, addition of Ginkgo biloba extract (GBE) in the amount of 240 mg per day effectively reversed the sexual dysfunction.7 This makes sense because ginkgo has been reported to help men with some forms of erectile dysfunction.8

St. John’s wort (Hypericum perforatum)
One report described a case of serotonin syndrome in a patient who took St. John’s wort and trazodone, a weak SSRI drug.9 The patient reportedly experienced mental confusion, muscle twitching, sweating, flushing, and ataxia. In another case, a patient experienced grogginess, lethargy, nausea, weakness, and fatigue after taking one dose of paroxetine (Paxil®, another SSRI drug) after ten days of St. John’s wort use.10

Interactions with Foods and Other Compounds
Food
Results of two nonblinded randomized studies in healthy people suggest sertraline may be taken with or without food.11

Alcohol
SSRI drugs, including sertraline, may cause dizziness or drowsiness.12 Alcohol may intensify these effects and increase the risk of accidental injury. Alcohol should be avoided during sertraline therapy.



1. McLeod MN, Gaynes BN, Golden RN. Chromium potentiation of antidepressant pharmacotherapy for dysthymic disorder in 5 patients. J Clin Psychiatry 1999;60:237–40.

2. Threlkeld DS, ed. Central Nervous System Drugs, Antidepressants, Selective Serotonin Reuptake Inhibitors. In Facts and Comparisons Drug Information. St. Louis, MO: Facts and Comparisons, Apr 1997, 264q-4r.

3. Walinder J, Carlsson A, Persson R. 5-HT reuptake inhibitors plus tryptophan in endogenous depression. Acta Psych Scand Suppl 1981;290:179–90.

4. Spigset O, Hedenmalm K, Mortimer O. Hyponatremia as a side effect of serotonin uptake inhibitors. Lakartidningen 1998;95:3537–9 [Swedish].

5. Strachan J, Shepherd J. Hyponatraemia associated with the use of selective serotonin re-uptake inhibitors. Aust N Z J Psychiatry 1998;32:295–8.

6. Bouman WP, Pinner G, Johnson H. Incidence of selective serotonin reuptake inhibitor (SSRI) induced hyponatraemia due to the syndrome of antidiuretic hormone (SIADH) secretion in the elderly. Int J Geriatr Psychiatry 1998;13:12–5.

7. Cohen AJ. Long term safety and efficacy of Ginkgo biloba extract in the treatment of anti-depressant-induced sexual dysfunction. Psychiatry On-Line http://www.priory.com/ginkgo.html.

8. Sohn M, Sikora R. Ginkgo biloba extract in the therapy of erectile dysfunction. J Sex Educ Ther 1991;17:53–61.

9. Demott K. St. John’s wort tied to serotonin syndrome. Clinical Psychiatry News 1998;26:28.

10. Gordon JB. SSRIs and St. John’s wort: possible toxicity? Am Fam Physician 1998;57:950.

11. Ronfeld RA, Wilner KD, Baris BA. Sertraline. Chronopharmacokinetics and the effect of coadministration with food. Clin Pharmacokinet 1997;32 Suppl 1:50–5.

12. Threlkeld DS, ed. Central Nervous System Drugs, Antidepressants, Selective Serotonin Reuptake Inhibitors. In Facts and Comparisons Drug Information. St. Louis, MO: Facts and Comparisons, Apr 1997, 264q.

Healthnotes Index:
Healthnotes:
Carbidopa/Levodopa

[ + Show other common brand and generic names- Hide other common brand and generic names ]
Also indexed as: Atamet, Sinemet

See also: Carbidopa

Skip to:
Introduction
Interactions summary
Vitamin interactions
Food interactions
References
Levodopa is required by the brain to produce dopamine, an important neurotransmitter. People with Parkinson’s disease have depleted levels of dopamine, leading to debilitating symptoms. Levodopa is given to increase production of dopamine, which in turn reduces the symptoms of Parkinson’s disease. When taken by mouth, most levodopa is broken down by the body before it reaches the brain. Sinemet® combines levodopa with carbidopa, a drug that prevents the breakdown, allowing levodopa to reach the brain to increase dopamine levels.

Summary of Interactions with Vitamins, Herbs, and Foods
In some cases, an herb or supplement may appear in more than one category, which may seem contradictory. For clarification, read the full article for details about the summarized interactions.

May Be Beneficial: Depletion or interference—The medication may deplete or interfere with the absorption or function of the nutrient. Taking these nutrients may help replenish them. Niacin*

May Be Beneficial: Supportive interaction—Taking these supplements may support or otherwise help your medication work better. Vitamin C*

Avoid: Reduced drug absorption/bioavailability—Avoid these supplements when taking this medication since the supplement may decrease the absorption and/or activity of the medication in the body. Iron

Check: Other—Before taking any of these supplements or eating any of these foods with your medication, read this article in full for details. 5-HTP

Vitamin B6

Side effect reduction/prevention None known

Adverse interaction None known


An asterisk (*) next to an item in the summary indicates that the interaction is supported only by weak, fragmentary, and/or contradictory scientific evidence.

Interactions with Dietary Supplements
Vitamin B6
Vitamin B6 supplementation above 5–10 mg per day reduces the effectiveness of levodopa.1 However, combining levodopa with carbidopa prevents this adverse effect, so vitamin B6 supplements may safely be taken with Sinemet® (carbidopa/levodopa).

Iron
Iron supplements taken with carbidopa interfere with the action of the drug.2 People taking carbidopa should not supplement iron without consulting the prescribing physician.

5-Hydroxytryptophan (5-HTP)
Several cases of scleroderma-like illness have been reported in patients using carbidopa and 5-HTP.3 4 5 People taking carbidopa should not supplement 5-HTP without consulting the prescribing physician.

Niacin
A study in animals has found that carbidopa inhibits an enzyme involved in the synthesis of niacin in the body.6 In addition, there is evidence that niacin synthesis is decreased in people taking carbidopa and other drugs in its class.7 Further studies are needed to determine whether niacin supplementation is appropriate in people taking carbidopa.

Vitamin C
Combining levodopa-carbidopa and vitamin C may be useful for people with Parkinson’s disease whose motor complications are not effectively managed with conventional drug treatment. This combination was administered to people with Parkinson’s disease in a preliminary study.8 The researchers reported several improvements in participants who completed the study; however, 62% of the participants withdrew from the study, most citing difficulty in performing normal movements. Until more research is performed, this drug-nutrient combination must be viewed as experimental.

Interactions with Foods and Other Compounds
Food
Food, especially foods high in protein, can alter levodopa absorption.9 10 However, Sinemet® is often taken with food to avoid stomach upset. Sinemet® and Sinemet® CR should be taken at the same time, always with or always without food, every day.



1. Trovato A, Nuhlicek DN, Midtling JE. Drug-nutrient interactions. Am Family Phys 1991;44:1651–8.

2. Campbell NR, Hasinoff BB. Iron supplements: a common cause of drug interactions. Brit J Clin Pharmacol 1991;31:251–5 [review].

3. Sternberg EM, Van Woert MH, Young SN, et al. Development of a scleroderma-like illness during therapy with L-5-hydroxytryptophan and carbidopa. New Engl J Med 1980;303:782–7.

4. Joly P, Lampert A, Thromine E, Lauret P. Development of pseudobullous morphea and scleroderma-like illness during therapy with L-5-hydroxytryptophan and carbidopa. J Am Acad Dermatol 1991;25:332–3.

5. Auffranc JC, Berbis P, Fabre JF, et al. Sclerodermiform and poikilodermal syndrome observed during treatment with carbidopa and 5-hydroxytryptophan. Ann Dermatol Verereol 1985;112:691–2.

6. Bender DA, Smith WR. Inhibition of kynurenine hydrolase by benserazide, carbidopa and other aromatic hydrazine derivatives: evidence for sub-clinical iatrogenic niacin deficiency. Biochem Soc Trans 1978;6:120–2.

7. Bender DA, Earl CJ, Lees AJ. Niacin depletion in Parkinsonian patients treated with L-dopa, benserazide and carbidopa. Clin Sci 1979;56:89–93.

8. Linazasoro G, Gorospe A. Treatment of complicated Parkinson disease with a solution of levodopa- carbidopa and ascorbic acid. Neurologia 1995;10:220–3 [in Spanish].

9. Threlkeld DS, ed. Central Nervous System Drugs, Antiparkinson Agents, Levodopa. In Facts and Comparison Drug Information. St. Louis, MO: Facts and Comparisons Drug Information, Apr 1998, 289p–90a.

10. Threlkeld DS, ed. Central Nervous System Drugs, Antiparkinson Agents, Levodopa. In Facts and Comparison Drug Information. St. Louis, MO: Facts and Comparisons Drug Information, Apr 1998, 289p–90a.

Benzodiazepines

[ + Show other common brand and generic names- Hide other common brand and generic names ]
Also indexed as: Ativan, Bromazepam, Centrax, Chlordiazepoxide, Clonazepam, Clorazepate, Dalmane, Diastat, Diazepam, Dizac, Doral, Estazolam, Flunitrazepam, Flurazepam, Halazepam, Klonopin, Libritabs, Librium, Loprazolam, Lorazepam, Lormetazepam, Midazolam, Nitrazepam, Paxipam, Prazepam, ProSom, Quazepam, Restoril, Temazepam, Valium, Versed

Skip to:
Introduction
Drugs in this category
Interactions summary
Vitamin interactions
Herb interactions
Food interactions
References
Benzodiazepines are a family of drugs used to treat insomnia, anxiety, panic attacks, muscle spasms, and seizure disorders. One benzodiazepine, midazolam, is used as a general anesthetic.

Summary of Interactions with Vitamins, Herbs, and Foods
In some cases, an herb or supplement may appear in more than one category, which may seem contradictory. For clarification, read the full article for details about the summarized interactions.

May Be Beneficial: Supportive interaction—Taking these supplements may support or otherwise help your medication work better. Vinpocetine

Avoid: Adverse interaction—Avoid these supplements when taking this medication because taking them together may cause undesirable or dangerous results. Alcohol

St. John's wort (alprazolam)

Depletion or interference None known

Side effect reduction/prevention None known

Reduced drug absorption/bioavailability None known

Interactions common to many, if not all, Benzodiazepines are described in this article. Interactions reported for only one or several drugs in this class may not be listed in this article. Some drugs listed in this article are linked to articles specific to that respective drug; please refer to those individual drug articles. The information in this article may not necessarily apply to drugs in this class for which no separate article exists. If you are taking a Benzodiazepine for which no separate article exists, talk with your doctor or pharmacist.

An asterisk (*) next to an item in the summary indicates that the interaction is supported only by weak, fragmentary, and/or contradictory scientific evidence.

Interactions involving benzodiazepines in general are described on this page. For interactions involving a specific benzodiazepine, refer to the highlighted drugs listed below.

Alprazolam (Xanax®)
Chlordiazepoxide (Librium®, Libritabs®)
Clonazepam (Klonopin®)
Clorazepate Dipotassium (Tranxene®)
Diazepam (Valium®)
Estazolam (ProSom®)
Flunitrazepam (Rohypnol®)
Flurazepam (Dalmane®)
Lorazepam (Ativan®)
Midazolam (Versed®)
Oxazepam (Serax®)
Quazepam (Doral®)
Temazepam (Restoril®)
Triazolam (Halcion®)
Interactions with Dietary Supplements —
Vinpocetine
In a preliminary trial, an extract of periwinkle called vinpocetine was shown to produce minor improvements in short-term memory among people taking flunitrazepam, a benzodiazepine.1 Further study is needed to determine if vinpocetine would be a helpful adjunct to use of benzodiazepines.

Interactions with Herbs —
Kava (Piper methysticum)
Kava is an herb used to treat anxiety disorder. One individual who took a benzodiazepine (alprazolam) and kava together, along with two other medications (cimetidine and terazosin) was hospitalized in a lethargic and disoriented condition.2 Further research is needed to determine whether the combination of kava and benzodiazepines produces an adverse interaction. However, individuals should not take benzodiazepines and kava together unless supervised by a doctor.

St. John's wort (Hypericum perforatum)
In a study of healthy volunteers, administration of St. John's wort along with alprazolam decreased blood levels of alprazolam, compared with the levels when alprazolam was taken by itself.3 Individuals taking alprazolam should not take St. John's wort without supervision by a doctor.

Interactions with Foods and Other Compounds
Alcohol
Drinking alcoholic beverages while taking benzodiazepines may increase side effects, such as drowsiness, confusion, and dizziness;4 if taken in excess, this combination may result in death. Consequently, people taking benzodiazepines should avoid drinking alcohol.



1. Bhatti JZ, Hindmarch I. Vinpocetine effects on cognitive impairments produced by flunitrazepam. Int Clin Psychopharmacol 1987;2:325–31.

2. Almeida JC. Coma from the health food store: Interaction between kava and alprazolam. Ann Intern Med 1996;125:940–1.

3. Markowitz JS, Donovan JL, DeVane CL, et al. Effect of St John's wort on drug metabolism by induction of cytochrome P450 3A4 enzyme. JAMA 2003;290:1500–4.

4. Olin BR, ed. Central Nervous System Drugs, Psychotherapeutic Drugs, Antianxiety Agents, In Drug Facts and Comparisons. St. Louis, MO: Facts and Comparisons, 1993, 1255–69.

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