Index

S. No. Topics Page

No.
1 Introduction 2-3

2 How food influence the efficacy of medicines 3-4

3 Medicines properties and how to take the medicines 5-6

4 How to know whether the medicine should be taken 7

before or after food?

5 When is the right time to take drugs: Before, after or 7 - 9

with meal?

6 How Some Foods Affect Some Drugs 9 - 14

7 Conclusion 14 - 15

8 References 15

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Introduction

Medicines are chemicals used to treat or prevent diseases. Certain

disorders or health problems can also be controlled with medicines. There
are various delivery routes of medicines; taken orally, applied as local
application, as injection, inhaled or administered into body orifices.

Pharmaceutical
Features Shape
dosage

Consists of various
shapes
Tablet
Scored tablet can be cut
into halves

Spherical shape
Pil
Cannot be cut

Consists of body and cap

Capsule
Cannot be cut

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 Consists of oval shell
Soft gelatin
filled with liquid
capsule (softgel)
Cannot be cut

Liquid form

Need to be measured
Syrup
with measuring device
before taken orally

Should be shaken well

before taken.
Suspension liquid
Need to be measured
(Liquid form)
with measuring device
before taken orally

Powder, granules or
crystal form.

Should be diluted with

Powder or granule
water or fruit juice before
taken

Certain medicines specifically should be taken before or after food.

How foods influence the efficacy of medicines

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Food can influence medicines efficacy through several ways:

a. Food stimulates production of gastric acid.

Stomach will produce acid to enhance food digestion.

Certain medicines such as erythromycin, isoniazid and azithromycin will

compromise when exposed to acidic condition. Acidic environment will
cause the medicine to degrade. Consequently, medicine absorption will
reduce and less medicine will be absorbed into body. As a result, the
medicine will become less effective. Hence, such medicine should be taken
during empty stomach.

However, there are also medicines which require acidic environment to

optimize absorption such as ketoconazole and itraconazole. Such
medicines should be taken after food.

b. Food can remove active ingredients of medicine through chelation

process

Certain food contain mineral such as calcium and ferrous. Certain

medicines such as bisphosphonates and ciprofloxacin will react and bind
themselves to the minerals. This process is called chelation process and
will cause the medicines to deactivate. Thus, such medicines should be
taken before food.

c. Absorption of certain medicines enhanced by bile secretion

Bile secretion enhances absorption of certain medicines such as

tacrolimus, carbamazepine and griseofulvin, thus such medicines are
suitable to be taken after food.

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 d. Rate of gastric emptying

Fatty food will reduce rate of gastric emptying. Reduction in rate of gastric
emptying will reduce absorption rate of the drug.

e. Physical adsorption

Certain medicines such as digoxin are easily adsorbed on high-fiber foods.

Thus, such medicines should not be taken with high-fiber foods.

f. Food effects on central nervous system

Food and beverages containing alcohol will cause depression on central

nervous system. Certain medicines such as chlorpheniramine, hydroxyzine,
dexchlorpheniramine and triprolidine can cause sleepiness and
drowsiness. Thus, such medicines should not be taken with alcoholic foods
or beverages. Alcohol will potentiate the effects of the medicines.

Medicines properties and how to take the medicines

Properties of the medicines will affect whether the medicine are suitable to
be taken before or after food:

a. Nausea and vomiting induced by the drugs

Certain medicines such as allopurinol, bromocriptine and combination of

levodopa + benserazide can induce nausea and vomiting. Such medicines
are suitable to be taken after food to reduce the side effects.

b. Irritation, difficulties in digestion, gastric ulcer induced by the drugs

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Certain medicines can irritate the stomach. Thus, such medicines are
suitable to be taken after food. For example: acetylsalicylic acid, non-
steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac and
ibuprofen and corticosteroid such as prednisolone and dexamethasone.

c. Medicines used to treat gastric acid reflux and digestion problems

Antacid is a medicine used to treat gastric acid reflux and digestion

problem which happens due to secretion of gastric acid after food entering
the stomach. Thus, antacid should be taken immediately after food.

d. To avoid medicines removed by foods.

Medicines used to treat oral thrush such as nystatin syrup and miconazole
gel should be used after food. Food will remove the medicines which
subsequently reduce the effectiveness of the medicine.

e. Food improves drug absorption

Medicines such as ritonavir, saquinavir, and nelfinavir are more easily

absorbed with the presence of food such as medicines which are suitable
to be taken after food.

f. Diabetic medicines

Diabetic medicines such as metformin and gliclazide should be ideally

taken with not too long after or before food. This is to avoid hypoglycaemia
and at the same time to ensure glucose blood level is not too high after
food.

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How to know whether the medicine should be taken before or after
food?

Instruction on how to take medicine is usually printed in the product leaflet.

If you are not supplied with such leaflet, you may obtain the information
from pharmacists.

Consumption of medicine before or after food will influence the medicine

bioavailability of the medicine in our body. Low bioavailability will reduce
the effectiveness of the medicine. Hence, it is important to take the
medicine in the right order.

When is the right time to take drugs: Before, after or with meal?

Does eating before taking our drugs or taking them after a meal affect the
efficacy of the drugs?

A number of us would have been told we should take our drugs after
eating, on an empty stomach, or not to take certain drugs with certain
foods. What are the factual bases of these instructions?

The truth is that such instructions are relative and depend on the type of
medication, the requirements accompanying a particular medication, as
well as the type of food we are taking.

Food Triggers Changes In The body

It is first important to understand that food might trigger changes in our

body. These changes include increasing the blood supply in the gut,
increasing bile and also the level of acidity. These changes that are linked
to our eating habits determine medication absorption. Hence the food we

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eat and the drinks we take affect medication and the response of a
person’s body to the medication.

Before or After?

Taking medication after eating or with food usually means taking

medication 30 minutes to one hour after a meal. For medication such as
non-steroidal anti-inflammatory drugs (NSAIDs) (ibuprofen, aspirin),
metformin for diabetes and steroid medication, these need to be taken after
eating.

With a few exceptions, and unless stated otherwise by a doctor, most anti-
malaria medications are also taken with a meal. This is important because
taking medicine after a meal not only ensures that medicine is absorbed
into the bloodstream but also prevents side effects, stomach irritation and
ulcers.

Taking medication on an empty stomach (before food) means at least two

hours after a meal and one hour before a meal. Some of the medications
that are required to be taken on an empty stomach include Antihistamines,
used to treat allergies, thyroid hormones and bisphosphonates, used for
bone protection. They are taken on an empty stomach because taking
them while eating prevents the stomach from absorbing the medication.

Please note that in instances where you do not seek directions from the
information provided on medication labels, always refer to a doctor or
pharmacist for advice on taking medicine. The doctor’s extensive
knowledge of a patient’s symptoms, their health history and specific health
needs make them the first-line for advice.

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How Some Foods Affect Some Drugs

On the other hand, some medicines can work better or are affected not
only by the presence or lack thereof of food in the stomach but also the
type of food or drink.

In 1989, a research group discovered that grapefruit and having grapefruit

juice interacts and interferes with some types of medication. The
medication that was found to be affected include statins that lower
cholesterol, an anti-hypertensive medication, medication for heart
arrhythmia, organ-transplant rejection medicines and anti-anxiety medicine.

An enzyme found in grapefruits known as CYP3A4 is responsible for

reducing the level of absorption of medicines. This is particularly important
as CYP3A4 is involved in the bioactivation of almost 50 per cent of all
drugs. Therefore, when grapefruit juice is consumed, the effectiveness of
the drug is reduced and it also augments the side effects of the medication.

Patients who take blood-thinning medication (anticoagulant) like warfarin,

phenprocoumon and acenocoumarol were advised to avoid dietary vitamin
K that can be found in leafy greens as it counteracts the effects of their
medication. However, a recent systematic review later found that the
effects of such foods were only detected for high vitamin K intake.

The review suggests 118 grams per day of raw lettuce green leaf
(equivalent to about one and a half cups of raw lettuce), 106 grams per day
of cooked broccoli (equivalent to about one and a quarter cups of cooked

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broccoli), or 30 grams per day of cooked spinach (equivalent to about one-
eighth of a quarter cup of cooked spinach) as a moderate amount in your
diet.

Hence to ensure the absorption of your medication, it is best to maintain a

consistent diet that is not filled with an excessive amount of leafy greens.

Alcohol

According to the U.S Food and Drug Administration (FDA), alcohol should
be avoided if you are taking medication due to an increased risk of adverse
effects. Consulting a doctor before you swallow your medicine with alcohol,
drinking alcohol after taking medication and taking medication after having
an alcoholic drink is important.

The FDA warns that alcohol taken with antihistamines causes drowsiness.
Pain relieving medication like paracetamol can cause severe liver damage
when mixed with three or more alcoholic drinks, regularly. Also, NSAIDs,
(drugs like diclofenac; a component of most body pain-relieving drugs sold
by pharmacies and drug hawkers) can cause stomach bleeding when
frequently mixed with three or more alcoholic drinks.

In addition, do not take alcohol with a narcotic analgesic, asthma

medication, statins, vasodilators-nitrates for treating angina, antibiotics,
antidepressants, antipsychotics, sleeping medication (sedatives) and
bipolar disorder medication.

Dairy Products

Dairy products like milk, yoghurt, cheese or calcium-fortified juices contain

calcium which affects certain antibiotics such as tetracycline and

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ciprofloxacin. Calcium and antibiotic interaction occur when calcium binds
to antibiotics and prevents their absorption to fight an infection, Neal Patel
from the Royal Pharmaceutical Society said.

He added, “Even if the milk affects just half of the drug, you’re only getting
half the dose, which could mean the infection isn’t killed off by the end of
the course.”

However, according to the FDA, it is safe to have a meal that contains the
dairy products in them, especially in small quantities.

Fruit Juices

Among all fruit juices, grape fruit juice (GFJ) possesses high interaction
with almost all types of drugs. The juice modifies the body’s way of
metabolizing the medication, affecting the liver’s ability to work the drug
through a person’s system.

Warfarin

Warfarin is commonly used to treat or prevent thromboembolic events.

Patients taking warfarin are at particular risk of interactions with dietary
supplements, yet approximately 30% use herbal or natural product
supplements on a regular basis. There is a possible interaction between
warfarin and a high-protein diet.

Monoamnine Oxidases

Antidepressant activity of monoamine oxidase inhibitors (MAOIs) was

initially noted in the 1950s. Although older monoamine oxidase inhibitors
(MAOIs) are effective in the treatment of depressive disorders, they are

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under-utilized in clinical practice due to main concerns about interaction
with tyramine-containing food (matured cheese, red vine, ripped bananas,
yogurt, shrimp paste and salami) or so-called cheese reaction, since they
are capable of producing hypertensive crisis in patients taking MAOIs.

Antihypertensive Drugs

Patients placed on anti-hypertensive drugs will benefit from concomitant

moderate sodium restricted diets. Propranolol serum levels may be
increased if taken with rich protein food. A change in diet from high
carbohydrates/low protein to low carbohydrate/high protein may result in
increased oral clearance. Smoking may decrease its plasma levels of by
increasing its metabolism. The intestinal absorption of celiprolol (beta-
blocker) is inhibited when it is taken with orange juice. Hesperidin, present
in orange juice, is responsible for the decreased absorption of
celiprolol. The absorption of ACEs inhibitors is increased when taken on an
empty stomach. While GFJ increases the bioavailability of felodipine,

Antibiotics

Antibiotics are widely prescribed in medical practice. Many of them induce

or are subject to interactions that may diminish their anti-infectious
efficiency or elicit toxic effects. Food intake can influence the effectiveness
of an antibiotic. Avoid co-administration of antibiotics with milk products
which are rich sources of divalent ions, such as calcium and magnesium
that complex with some antibiotics and prevent their absorption. The intake
of dairy products, however, needs to be monitored and encouraged with
appropriate consideration of specific antibiotics involved.
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Analgesics and Antipyretics

Analgesics and antipyretics are used to treat mild to moderate pain and
fever. For rapid relief, acetaminophen should be taken in an empty
stomach because food may slow the body absorption of acetaminophen.
Co-administration of acetaminophen with pectin delays its absorption and
onset. NSAIDs like ibuprofen, naproxen, ketoprofen and others can cause
stomach irritation and thus they should be taken with food or milk. Avoid or
limit the use of alcohol because chronic alcohol use can increase the risk of
liver damage or stomach bleeding.

Bronchiodilators

Bronchodilators like theophylline, albuterol, and epinephrine possess

different effects with food. The effect of food on theophylline medications
can vary widely. High-fat meals may increase the amount of theophylline in
the body, while high-carbohydrate meals may decrease it. Avoid alcohol if
taking theophylline medications because it can increase the risk of side
effects such as nausea, vomiting, headache and irritability. Avoid eating or
drinking large amounts of foods and beverages that contain caffeine (e.g.,
chocolate, colas, coffee, and tea) since theophylline is a xanthine derivative
and these substances also contain xanthine. Hence consuming large
amounts of these substances while taking theophylline, increases the risk
of drug toxicity.

Antihistamines

Fexofenadine, loratadine, rupatadine, cimetidine cetirizine, are all

antihistamines. It is best to take prescription antihistamines on an empty
stomach to increase their effectiveness.
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Antitubercular Drugs

Anti-tubercular drugs like isoniazid have been associated with tyramine and
histamine interactions. Inhibition of monoamine oxidase and histaminase
by isoniazid can cause significant drug-food interactions. Food greatly
decreases isoniazid bioavailability. Oleanolic acid, a triterpenoid exists
widely in food, medicinal herbs and other plants, has antimycobacterial
activity against the Mycobacterium tuberculosis, when administered with
isoniazid, it exerts synergistic effect.

Antidiabetics

Glimepiride is an antidiabetic and a new generation sulfonylurea derivative

should be administered with breakfast or the first main meal of the day. It
has absolute bioavailability and the absence of food interaction guarantee
highly reproducible pharmacokinetics. Immediate release glipizide should
be taken 30 minutes before meals. However, extended release tablets
should be taken with breakfast. The maximum effectiveness of acarbose,
an alpha-glucosidase inhibitor is attained when the drug is taken
immediately at the start of each meal (not half an hour before or after),
because it delays the carbohydrate absorption by inhibiting the enzyme
alpha-glucosidase.

Conclusion

In saying this, the aim is that we improve the effectiveness and safety of
our medication by thinking carefully about when we take them. The various
foods mentioned do not imply that we completely eliminate them from our
diets as they include foods that form a holistic, nutritional and balanced
diet.
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Rather, this offers a guide underpinned by experts advice that will help
those taking the medications listed. Indeed, Dima Qato, a pharmacist and
assistant professor at the University of Illinois, Chicago, who studied food
and drug interaction, advised that “leaving at least two to four hours
between the interacting food or juice and the medication is usually
recommended.”

“These interactions, therefore, can serve within the body to enhance

behaviours that aid the action of the drug, delay its actions, complement its
action or completely block its actions.

“When the medication label says to take with a meal or after a meal, for
instance, this simply implies that fat in the food can either delay or enhance
absorption of such a drug

References

1) https://www.premiumtimesng.com/health/health-interviews/321376-
when-is-the-right-time-to-take-drugs-before-after-or-with-meal.html?
tztc=1
2) http://www.myhealth.gov.my/en/medicines-before-after-food/
3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191675/

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