Maggie McKay (Host): Have you ever wondered if you can safely mix certain medicines with supplements? Today, Retail Pharmacy Operations Manager, Kylie Gordash, will discuss supplements and drug interactions, answering some of the questions you may have. Welcome to, To Your Health, a podcast from Jefferson Healthcare. I'm your host, Maggie McKay.

Kylie, thank you so much for being here today.

Kylie Gordash, Pharmacist: Oh, thank you for having me.

Host: Absolutely. Would you please introduce yourself?

Kylie Gordash, Pharmacist: Yes, so I am Kylie Gordash. I work for Jefferson Healthcare. I am the Retail Pharmacy Operations Manager.

Host: So let's just start with what is a dietary supplement?

Kylie Gordash, Pharmacist: So, dietary supplements, they are things that we ingest and they're intended to add to our diet or supplement, but the key word is ingested. They have to be taken orally. They come in a variety of dosage forms, tablets, capsules, even gummies, bars, you name it, they've come a long way, but they have to be ingested.

 If they are applied topically, we would consider it like a cosmetic. If they are injected, it would be like a prescription medication.

Host: How else are they different from medications?

Kylie Gordash, Pharmacist: What it boils down to is what they claim to do and the approval process in getting them to the market. So if a product claims to treat, diagnose, cure, or even prevent a disease, it has to be classified as a drug. So dietary supplements cannot make those claims. As well, when we compare them to prescription medications, they're subject to much more stringent approval processes, they are studied more than dietary supplements.

But at the end of the day, a similarity that they share is that consumers use them both to try and improve their health.

Host: What should someone look for when they go to buy a dietary supplement?

Kylie Gordash, Pharmacist: There are a few things to look for. You really want to be purchasing a high quality dietary supplement. The first thing that you want to look for is something called a drug extraction ratio. And really what that is, is it's the quality indicator. Products that list drug extraction ratios, they're considered superior.

And, you can get differences in extractions due to differences in batches, which can vary with the season, the harvest, environmental conditions. So, the drug extraction ratio guarantees batch consistency, but what it does not do is it does not account for other ingredients present in the final extract. So then, we can go one step further and look for standardization, and that will quantify the specific compounds in the final extract.

Host: So how significant are interactions between medications and dietary supplements?

Kylie Gordash, Pharmacist: Really depends on the medication involved and the specific dietary supplement. In some cases, there can be very significant interactions between the two that actually result in safety concerns. While in other cases, there may technically be an interaction, it might not be all that clinically significant.

Host: Kylie, what steps should a consumer be taking to protect themselves against the consequences of interactions between dietary supplements and medications?

Kylie Gordash, Pharmacist: The best way to protect yourself against interactions between your medications and dietary supplements would be to ask your doctor or pharmacist before combining the two. There are so many different interactions that can occur and your doctor and pharmacist are uniquely positioned to help determine which combinations of medications and dietary supplements are safe and which ones are not.

Host: So what's happening in the body when an interaction is occurring, whether it's an interaction between medications or between dietary supplements and medications?

Kylie Gordash, Pharmacist: Well, when an interaction occurs, generally what tends to happen is that with one of the products involved, the levels either increase more than it should, or they may decrease more than they should. So it's almost as if you inadvertently raise or lower your dose, depending on, what interaction is occurring.

Host: Kylie, are there different types of interactions?

Kylie Gordash, Pharmacist: Actually, there are several different types of interactions, between medications and dietary supplements. If we want to break it down into two general categories, we could say that interactions fall into either like a kinetic interaction or dynamic interaction.

Host: What are those?

 Thank you.

Kylie Gordash, Pharmacist: So, kinetic interactions, I kind of like to focus on the root word kinetic, wich means, motion, and those interactions, they follow the motion of the drug molecule throughout the body. So, like, for example, when you swallow a tablet. Those drug molecules literally travel on a journey as they move throughout the body. The tablet, it has to go through the digestive system. Then it gets absorbed into the bloodstream. From there, it goes to the liver whose job is to try and remove foreign substances from the body. So, kinetic interactions, they interfere with those motion processes as that molecule travels through the body.

Now, a dynamic interaction, those are a little more complicated. They tend to occur when the medication is at its site of action, or sometimes you'll hear it referred to as the receptor site, and you can get situations where one molecule, let's say a dietary supplement molecule, it interferes with how, let's say, a drug molecule is binding at the site of action, and sometimes it'll make that molecule bind better and you get more of an effect than you would normally anticipate.

And in other cases, you can have where let's say the dietary supplement, it interferes with the binding and then that drug molecule does not do its job at the site of action.

Host: And can you elaborate more on the kinetic interactions, the four types?

Kylie Gordash, Pharmacist: The kinetic interactions, if we start with the first process, that would be the absorption, and that's a very common type of interaction that we see. We expect to absorb a certain amount of medication into the bloodstream, but if we have, let's say, a dietary supplement that interferes with that process, then, we're either going to maybe absorb more than we anticipate or, less.

Now, if we absorb more medication than what is intended, our side effects are going to go up. You may even experience toxicities in some cases, and then on the opposite end of the spectrum, if it interferes with that absorption process and we don't absorb what we expect to in the bloodstream; we won't have enough medication available to really do its job. As far as, when we get to the next step where the medication is absorbed and the first organ system that sees it is the liver. It's job is to help remove these foreign substances from the body and it does that through liver enzymes and I would say it's fairly common, in pharmacy to encounter where, we have these enzyme interactions and you can have two types.

One we call, inhibitory where the dietary supplement, it inhibits or prevents the enzyme from doing its job. Then you get more drug molecules entering the overall systemic circulation. And again, your blood levels climb, your side effects can go up, and in some cases toxicity.

And you can also get the opposite, where certain dietary supplements, they will induce liver enzymes. And that means that you get more liver enzymes, and they're much more effective, so they break down far more drug molecule than we would expect, and less drug molecule is available to do its job at the site of action.

Host: And what are some real life examples of interactions between dietary supplements and medications?

Kylie Gordash, Pharmacist: Well, if we're talking about absorption interactions, a very common one would be several dietary supplements contain minerals like calcium or magnesium, and they can very easily bind certain medications. For example, thyroid hormones are a perfect example. There are many people that use Synthroid or levothyroxine to treat a low thyroid.

And, they are not absorbed that well at the best of times, but when you introduce minerals like calcium and magnesium, the absorption is drastically decreased and then your low thyroid symptoms won't be controlled as well. Another example would be certain osteoporosis medications like alendronate, to try and help build stronger, healthier bones, have very poor absorption and if taken with anything other than a glass of water, for example, you may not even absorb any of it, particularly if you combine it with calcium, magnesium, vitamin, mineral supplements. In terms of absorption interactions, I would say those are fairly common.

Other real life interactions would be if we want to go the avenue of the liver, in terms of inducing enzymes, St. John's wort is commonly used for depression and it induces these enzymes and we get a decrease in the effectiveness of medications such as oral contraceptives.

They won't work as well. Immunosuppressants, let's say like a patient if they're on like an organ transplant regimen, they need their immunosuppressant to work. And if they combine it with St. John's wort, those liver enzymes are going to break that medication down and it's not going to be available to do its job.

So, those are just a few, common, interactions that you can see with liver enzymes.

Host: Wow, so it sounds like the consequences could be pretty serious, especially, the one you mentioned about lessening the effectiveness of contraception.

Kylie Gordash, Pharmacist: Absolutely, yes. can have very significant consequences. Another example with this whole induction of enzymes, Valerian Root. It's a very common over the counter dietary supplement that can be used to help with insomnia, and it also can induce enzymes, and some of the medications it affects are there's a blood thinner called clopidogrel, and if, if this blood thinner isn't able to do its job because less of it is reaching the site of action, your risk of blood clot goes up or, simvastatin is a very common cholesterol medication to reduce the risk of heart disease.

If a person were to take valerian with that, you have less simvastatin to get your cholesterol numbers in check, and over time, it just won't be doing its job. And you might not even know that until your follow up appointment where your provider does blood work.

Host: I know some people who aren't on any medication, but they take a ton of supplements. Can the supplements themselves interact with each other in a negative way?

Kylie Gordash, Pharmacist: They can, that's definitely, a possibility. I wouldn't say it's as common as with the prescriptions and, in part, we have a lot more information available to us regarding prescription medication, dietary supplement interactions versus, combining dietary supplements. But yes, that also is a scenario that could be encountered.

Host: So basically, we should probably check with our doctor if we're on any medication before we take a supplement in addition.

Kylie Gordash, Pharmacist: Absolutely. That's the best bet.

Host: Always ask the doctor first, they know best.

Kylie Gordash, Pharmacist: Or your pharmacist too.

Host: Kylie, what's one big take home that you'd like our listeners to have regarding dietary supplements?

Kylie Gordash, Pharmacist: I would say the biggest take home I would like listeners to have is, just the importance of knowing that these interactions can and do exist between medications and dietary supplements and that the consequences can be severe. So, always ask your doctor or pharmacist before taking a dietary supplement.

We're here to help guide you in the safe use of medications and dietary supplements. So, use your doctor, use your pharmacist as that resource to help you make those decisions when considering a dietary supplement.

Host: That's great advice, especially since sometimes it can take forever to get a hold of your doctor or to get an appointment.

Kylie Gordash, Pharmacist: Oh, absolutely. And, in some cases too, from a pharmacist perspective, it can actually take certain amount of time just to go through all the different medications and supplements. Sometimes, we have to do our research and then get back to the patient through a phone call, for example.

Some of the interactions, just the screening process, it can take a little bit of time, so I wouldn't be surprised if your pharmacist asks for your phone number and to get back to you once they do all of their research.

Host: That's good to know. Well, thank you so much for sharing this invaluable information. We so appreciate your time. And I don't know, I have learned a lot myself.

Kylie Gordash, Pharmacist: Well, my pleasure. It was great being a part of this.

Host: Again, that's pharmacist Kylie Gordash. To find out more, please visit jeffersonhealthcare.org. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay. Thank you for listening to, To Your Health, a podcast from Jefferson HealthCare.