HEALTH: GRAPEFRUIT AND GLOVES

It may be my advancing age; it may be my own Katrina sequelae [a medical term for complications caused by a disease]. It’s probably a bit of both, but plain old stupid health pronouncements presented as absolutes continue to flame my fire and stir my pots.

“You cannot drink grapefruit juice if you are on cholesterol lowering medications” and “Patients are not safe unless doctors and nurses wear gloves for all hospital contacts” are two recent examples.

The first “factoid” comes from your neighborhood pharmacy as a stick-on label on an increasing number of prescription drugs. The second comes as a newly instituted poor piece of policy from a local hospital with a real or maybe even perceived outbreak of infection with Acinetobacter, a bacterium associated with increasing resistance to antibiotics.
Oftentimes, there is at least a small glimmer of truth in medical information promulgated as factoids in the popular press, over the airways and through the Internet. Skepticism, however, remains the most valuable tenet I was taught in medical school.

December is a big grapefruit month. They’re growing in Plaquemine Parish, they’re in the grocery stores, and they’ll be in the UPS vans soon. Harry and David, those all-American fruit-growing boys in Oregon, seem to have a direct link to distant aunts and friends who order yearly for holiday delivery.

More and more prescription bottles are being labeled with a sticker “Do not take this medication with grapefruit juice.” Hardly a week goes by that a patient doesn’t ask me about grapefruit juice. Since grapefruit availability peaks with Christmas, I figured finding someone who suffered an adverse effect by mixing grapefruit juice and a medication would be simple. I sent e-mail inquires to over 100 New Orleans physicians.

“We psychiatrists have been warned that the enzyme needed to break down a chemical in grapefruit is the same one needed to metabolize Zoloft. So don’t take Zoloft and drink grapefruit juice at the same time because Zoloft levels will increase to harmful levels. But, no, I have never actually had this happen with a patient, and I have many on Zoloft,” responds Dr. Ed Foulks, a past president of the Orleans Parish Medical Society.

“The only time I have seen a problem is in patients with canker sores. [Grapefruit] juice burns like liquid fire,” responds Dr. Michael Ellis, the never bashful e-mailing otolaryngologist.

My good friend and neighbor was afraid to drink a Sea Breeze at my house during the waning days of the summer. This cooling summer cocktail is half vodka and half cranberry juice poured over ice with a splash of grapefruit juice.

“Are you trying to kill me? I can’t drink that. It has grapefruit juice in it, and you prescribed the Lipitor for me. My Lipitor costs too much to have it canceled out by grapefruit juice,” she scolded.

Indeed, she was correct about a possible interaction between grapefruit juice and Lipitor, but she had the potential change in the Lipitor bioavailability going in the wrong direction.

According to Prescriber’s Letter, [a medical industry newsletter,] grapefruit juice can increase serum concentrations of Lipitor and its metabolites by about 25 percent. Theoretically, this means that a grapefruit drinker taking 20mg of Lipitor would get the same therapeutic level of a non-drinker taking 25mg, moving this food-drug interaction into the realm of no clinical significance, a concept better understood by physicians in the trenches than by pharmacologists in the laboratory.

Grapefruit juice partially inhibits an enzyme in the gastrointestinal tract that breaks down the Lipitor molecule. This causes an increase in the absorption of Lipitor. All the commonly prescribed statins are absorbed and metabolized differently. Pravachol and Lescol levels do not seem to be affected by grapefruit juice. [see box]

According to Prescriber’s Letter, the “grapefruit effect” is most pronounced in people taking Mevacor or Zocor, as levels in these grapefruit drinkers can be boosted to 300 percent of normal. At these high levels, there is a concern that the incidence of adverse effects will soar, but it likely would take ounces of grapefruit juice daily to cause the generalized muscle weakness called myopathy, the most common adverse effect of high dose statins.

Prescriber’s Letter advises physicians to tell patients taking Mevacor or Zocor that they should not drink grapefruit juice, as taking the drug even several hours after the juice may still cause the problem – and the effect – to last 24 hours or more. As for Lipitor, they are more generous: “Tell Lipitor patients it’s probably okay to have an occasional glass of grapefruit juice … but not to make it a regular habit. If you want to avoid any chance for a complication with grapefruit juice and statins, use Pravachol or Lescol.”

The second “factoid” to attract my ire was the institution of a hospital-wide gloving policy for all patient contacts based on a pronouncement that a hospital “has had a cluster of multiple drug resistant Acinetobacter with the likely transmission through the hands of personnel.”

This policy must have warmed the hearts of the companies selling these gloves. Hand washing is, of course, next to godliness, and I am not about to say the practice is unnecessary. However, most hospital infections occur in patients whose own bacterial flora has gone amuck from wide-spectrum antibiotics prescribed for other problems.

Based on some downright bad advice that didn’t even include special testing to show that the small increase in the isolation of Acinetobacter bacteria were of the same strain, the “infections” were attributed to transmission through the hands of personnel. Well-documented studies show this bacterium classically inhabits environmental surfaces and things like ventilator tubes rather than physicians’ hands.

“I wonder what the patients think. Since only the doctors are even trying to wear the gloves, they must be concluding that there is something uniquely wrong with the doctors,” says one physician.

Whether referring to life in general, or medicine in specific, H.L. Mencken had it right: “There is always an easy solution to every human problem – neat, plausible and wrong.”

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