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Old 12-03-2019, 09:45 PM
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Statins and seltzer


My wife is on statins, which means she can't have grapefruit. But she does love her grapefruit.

Now there are plenty of grapefruit seltzers on the market. I assume they use natural grapefruit flavor. The question is whether the flavor contains the chemical that creates the problem.

Also, since there's far less grapefruit in seltzer, is it likely to cause an interaction problem?
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Old 12-03-2019, 10:05 PM
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Talk to your pharmacist or Primary care doc. Both of mine told me not to worry when I asked about both fruit and full strength juice. (My dose is on the low side).

Based on that, I can't imagine a problem with seltzer.
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Old 12-03-2019, 11:17 PM
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Only some statins are affected by grapefruit.

Two that are not (to any relevant degree) are pravastatin (Pravachol) and rosuvastatin (Crestor).

Here's a link to a seemingly reputable (and brief) article on the topic and I draw your attention to the table it contains.
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Old 12-04-2019, 07:31 AM
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Quote:
Originally Posted by KarlGauss View Post
Only some statins are affected by grapefruit.

Two that are not (to any relevant degree) are pravastatin (Pravachol) and rosuvastatin (Crestor).

Here's a link to a seemingly reputable (and brief) article on the topic and I draw your attention to the table it contains.
That's interesting since I use pravachol and the pharmacist's label proscribes grapefruit entirely. I used to love grapefruit. I would eat a whole fruit, peeling it like an orange and gnawing off sections. The linked article makes it sound like that is even less likely to cause a problem. I will ask my doctor.
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Old 12-04-2019, 07:41 AM
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I dont think seltzer has any actual fruit content. Its just flavoring. I understand that grapefruit is a very popular seltzer flavor.

(Personally, I hate grapefruit. An orange that tastes like aspirin. Yech. Being on Lipitor has given me a great excuse to turn down any offers of grapefruit.)
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Old 12-04-2019, 08:49 AM
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I thought I heard somewhere that it was only either red or white grapefruit that was the problem, the other being fine. But people like to be on the safe side and just avoid grapefruit altogether.

Having said that, I've talked to people in the juice industry who have said that as the grapefruit/medication interaction got more and more popular over the last 20 years or so, they've all but eliminated grapefruit based juices from their lineup. One person that owns a (very large, nationally distributed) juice business mentioned that 20 years ago, they were bottling grapefruit juice every few days, now it's maybe once a month.

I'm not sure if the stats are going to be available anywhere on the internet, but it would be interesting to see how that lines up with sales of Squirt or Ocean Spray grapefruit juice over the past few decades.
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Old 12-04-2019, 09:23 AM
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Here is an article from the Cleveland Clinic to discuss with your physician.

Quote:

There is no absolute consensus about how much grapefruit a person can safely eat while taking statins, but Dr. Hazen takes a measured approach with his patients.

I personally tell my folks who have had no issues with taking a statin, Go ahead and eat the grapefruit, but in moderation. Better they eat a low-calorie fruit and if we find symptoms of statin intolerance, we can cross that bridge, if need be.

Dr. Hazen says the original studies linking grapefruit ingestion to delayed statin metabolism involved over two quarts of grapefruit juice per day.

A more reasonable level of grapefruit consumption has been shown to result in far less effect on statins, he says, adding that patients should still talk with their doctor before eating grapefruit if they take statins.
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Old 12-04-2019, 09:27 AM
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Quote:
Originally Posted by Hari Seldon View Post
That's interesting since I use pravachol and the pharmacist's label proscribes grapefruit entirely . . .
Often (and maybe always), pharmacists and on-line drug interaction checkers will label ALL members of a drug class with a caution or even a contraindication, when only one or some members of the class are affected.

Take a look at Table I in this CMAJ article from a few years ago that not only documents for which drugs grapefruit MUST be avoided, but also lists alternatives of the same class.

BTW, Pravachol and Crestor not only are immune to the grapefruit interaction, they also have a very much lower chance of causing the muscle breakdown (rhabdomyolysis) that is THE big risk for people using statins (however rare).
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Old 12-04-2019, 09:28 AM
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I, too missed my grapefruit when my doc put me on statins. I mentioned it to him and he told me that I could still eat grapefruit; I just couldn't eat it with the statins. He explained that the enzyme in grapefruit that knocks out the statin can only do it while both are in the stomach. So I take my meds and eat my grapefruit an hour later. (He told me 20-30 minutes, but I wanted to be safe).
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Old 12-04-2019, 09:28 AM
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Quote:
Originally Posted by Acsenray View Post
I don’t think seltzer has any actual fruit content. It’s just flavoring. I understand that grapefruit is a very popular seltzer flavor.
Spindrift Seltzer (which I find very tasty) claims 10% real fruit juice In their grapefruit seltzer.

Last edited by jasg; 12-04-2019 at 09:29 AM.
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Old 12-04-2019, 10:13 AM
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Quote:
Originally Posted by Emergency911 View Post
He explained that the enzyme in grapefruit that knocks out the statin can only do it while both are in the stomach..
According to this study, not necessarily.

Quote:
Originally Posted by Study Abstract
Results

...The relationship of time after grapefruit juice exposure versus AUC increase over control indicated a recovery half‐life estimated at 23 hours

Conclusions

A usual single exposure to grapefruit juice appears to impair the enteric, but not the hepatic, component of presystemic extraction of oral midazolam. Recovery is largely complete within 3 days, consistent with enzyme regeneration after mechanism‐based inhibition. 6′7′‐Dihydroxybergamottin was verified as a potent mechanism‐based inhibitor of midazolam α‐hydroxylation by CYP3A in vitro.
In other words, the enzyme suppressed by grapefruit doesn't recover immediately. Your body recovers its ability to process statins slowly, about half of the knocked-out capability every 23 hours. Impacts up to 3 days after ingestion of grapefruit.

I don't know if this study is the final best word on the subject, however.

Last edited by gnoitall; 12-04-2019 at 10:14 AM.
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Old 12-04-2019, 10:38 AM
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I take atorvastatin (Lipitor), and my doctor says it's ok to drink Ocean Spray "Diet" grapefruit juice. It's not the same as regular juice, but a good compromise.
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Old 12-04-2019, 10:47 AM
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Quote:
Originally Posted by Acsenray View Post
I dont think seltzer has any actual fruit content. Its just flavoring. I understand that grapefruit is a very popular seltzer flavor.
"Natural grapefruit flavor" may come from a grapefruit (e.g. skin oils) even if it contains zero percent juice. Or the flavor may be bacteria poop. Or something else. Some of the flavor compounds in actual grapefruit also have drug interactions, but the compounds in grapefruit flavor may be the same or completely different.
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Old 12-04-2019, 10:53 AM
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Originally Posted by panache45 View Post
I take atorvastatin (Lipitor), and my doctor says it's ok to drink Ocean Spray "Diet" grapefruit juice. It's not the same as regular juice, but a good compromise.
I started last week. Neither the doctor nor pharmacist said a thing about grapefruit. The SDMB probably saved my life.
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Old 12-04-2019, 01:18 PM
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My father's doctor told him not to have them at the same meal, as the statins would not be as effective.

Since my father lost weight, his latest blood test indicates that he doesn't need any statins so he can go back to freely drinking grapefruit juice.
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Old 12-04-2019, 03:51 PM
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Originally Posted by Procrustus View Post
I started last week. Neither the doctor nor pharmacist said a thing about grapefruit. The SDMB probably saved my life.
It wouldn't kill you, it just makes them less effective. You would just get a cholesterol screen later and the doctor would notice the meds aren't working and hopefully your grapefruit addiction would come up.
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Old 12-04-2019, 03:54 PM
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Originally Posted by thelurkinghorror View Post
It wouldn't kill you, it just makes them less effective. You would just get a cholesterol screen later and the doctor would notice the meds aren't working and hopefully your grapefruit addiction would come up.
Youre probably right. I was overreacting to this from the article.

Quote:
Grapefruit juice contains compounds called furanocoumarins that stop CYP3A from doing its job. As a result, more of the drug is absorbed, making it more powerful than it's meant to be even toxic in some cases.
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Old 12-05-2019, 05:05 AM
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Originally Posted by thelurkinghorror View Post
It wouldn't kill you, it just makes them less effective. You would just get a cholesterol screen later and the doctor would notice the meds aren't working and hopefully your grapefruit addiction would come up.
No, this is not the issue. Grapefruit is metabolised by an enzyme called CYP3A4. It just so happens that this is the enzyme responsible for metabolism of many pharmaceuticals, including some statins. Metabolism of grapefruit (specifically the furanocoumarins it contains) "uses up" the CYP3A4 - the net result being that the drug in question - in this case a statin - is not metabolised as fast as expected, and so it can build up in the body, effectively creating an overdose and leading to the toxicities expected with overdosing.

This does not make the drug in question "less effective" - and in extreme cases with some drugs it could kill you. Certainly it has the potential to harm you. The two things that are important are (a) is the statin in question metabolised by the 3A4 pathway; and (b) does the selzer contain the 3A4 inhibitors?

It's such a well known interaction that it's pretty easy to figure out if the statin in question would be a problem. The potentially more difficult question, as others have pointed out, is whether the selzer in question contains the problem chemicals in significant quantity.

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