The Complexities of Drug - Drug Interactions

Last week I had the opportunity to join the Functional Health Team Academy Educational and Networking Event on "The Complexities of Drug - Drug Interactions," presented by Kurt Grady, PharmD, MBA.  Kurt is a successful healthcare and business leader currently working in the health economics and in the outcomes research arena of the biopharmaceutical industry. Rooted in advanced degrees from the St. Louis College of Pharmacy (Pharm.D.) and Southern Illinois University (MBA), he has forged a broad and varied clinical and business career. Knowing that balance is imperative to personal and professional growth, Kurt also holds a Doctorate in Biblical Studies (Biblical Counseling) and serves several colleges and organizations teaching medical issues in counseling both domestically and internationally.

Kurt discussed how pharmaceuticals and everything else breakdown into one category -- chemicals.  It's all chemicals, regardless of whether we are talking about drugs, supplements, herbs, vitamins, foods, essential oils, cleaning products, and even what we breath.  Water is a chemical.  

In talking about chemicals we discussed 4 basic concepts - Absorption, Distribution, Metabolism, and Elimination (ADME).  Absorption is how a drugs gets into the body and there are different ways this can happen.  Having been in the biomedical and veterinary fields, we utilized many different methods of absorption: oral, intravenous, subcutaneous, intramuscular, inhaled, topical, etc.  When I broke my arm in 2013, riding in a bouncy ambulance, I opted for intranasal administration of pain medication knowing an alternative method of administration for the drug they were going to give me.  

Absorption methods determine how "bioavailable" a chemical is to the body. If something is taken orally, it has to be absorbed from the gut, and often ends up in the liver first.  Here in the liver the drug may be changed, or unchanged.  Some drugs rely on the liver changing them into a metabolite, cutting part of the original chemical off, attaching parts to it, etc to make it "active," whereas others may be rendered less active.  

After absorption via a certain route, the chemical must be distributed to its target tissue.  A chemical has to be carried via the bloodstream, and cross into its specific tissue.   Many times chemicals in blood are transported bound by proteins in the blood.  When chemical changes occur, the chemical is let go from the protein and is able to diffuse or be actively transported into its target tissue.  

Metabolism is how chemicals are unfolded, changed, hacked up and repackaged to get it out of the body.  The liver OWNS metabolism!   The goal of metabolism is to  unmask and create handles that enzymes can grab onto to make everything either hydrophilic (water-loving) to be able to eliminate the chemical via urine, or lipophilic (fat loving) to eliminate the chemical via bile through feces.  Some other elimination pathways are via our respiratory system in the form of aromatic compounds like ketones, ammomia, etc,  and there are more locally specific routes such as sweat, oils, earwax, tears, etc.  

Elimination is where the chemical exits the body - either by way of renal excretion via urine, or via fecal matter.  Some may be reabsorbed, like theobromide a chemical found in chocolate can be reabsorbed in the bladder, or B vitamins from fecal matter in the large intestinal tract.  

When it comes to chemicals nothing is inconsequential!  Even simple compounds have interactions.  Those "inert" or "inactive" ingredients do count and do have effects.  There are intended interactions, but there are also unintended interactions.  Many variables determine how a chemical from any source may affect a person, and its effects can be different in each individual.  

Variables that effect chemical interaction:

Genetics
Epigenetics
Age
Gender

Poly-Pharmacy
Drug ADME
​Diseases

Nutrition
Foods
​Hydration

Environment
Smoking
​Alcohol

When it comes to drugs, and everything else we put into and on our bodies, it's essentially like having one bucket, and many holes that are always changing.  There is not much education in drug induced nutritional deficiencies, drugs interactions with foods, supplements, herbs, etc. In fact, there isn't much study in drug interactions involving the use of more than 2 drugs, or specific compounds as many of these interactions are studied on a one to one bases.  When we get into the use of multiple drugs - it's really anyone's guess, especially when assessing more than 5 interactions.  There exist unintended interactions and a combination that may be okay in one person, may not be okay in another.  Inert ingredients really aren't and even changes from one brand to another brand may causes unknown problems.  One thing to always remember - You are not a P-value. While research may suggest that a drug does one thing or has certain unintended effects, there may be more to be seen when used in indifferent individuals along with different compounds.  We can't ignore the consequences unique individuality - it's not one size, fits all.  

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As a doctor that chooses to treat without the use of pharmaceuticals, I do use supplements, herbs, oils, and foods to treat patients.   I recommend the use of cleaning products that don't use a lot of chemicals.  I must be educated in their applications, affects, utilization, and interactions.  A supplement I recommend may change how other medications works.  Some people may seek out my assistance for that very reason.  A medication may cause a nutritional deficiency, such as the popular metformin, and many birth control drugs.  A supplement I use may elucidate an unintended interaction causing side effects of another.  Supplements are not an inexpensive method to escape pharmaceutical intervention, nor are they all safe.  They too come with unintended interactions depending on the same variables stated above.  This is why I do want to see the bottle, know the brand, see the dose, and know what form of a vitamin is being used.  This is why I caution the use of supplements and herbs without knowing their possible interactions and unintended effects.  This is why I may also write letters to a physician asking them to "please consider" a lower dose, a different brand, or even a trial of elimination due to unintended interactions, or diminished benefit.  

"Have a problem, take a pill," was a mindset that even I ascribed to in my younger years.  Pills only work, until they don't, and there's no telling the interactions, depletions, and loss of function that can occur.  One area that I love to explore is how our genetics affects how medications work in individuals.  We are all genetically unique, and there are endless possibilities of combinations of functions and mutations that occur.  One pill, does not fit all and many can be made more effective by lifestyle interventions like nutritional changes, increased activity, probiotics, and even supplements given certain genetic mutations or depletion.

So, please consider that not all problems are solved by pills alone, and enjoy this clip from Fridays - The Pharmacist.   

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