No, a little sugar is not enough to make the pill go down, as Mary Poppins, the unforgettable magical nanny in the Disney cult film, sang. “I don’t want to hurt a character who takes me back to my childhood, but we already eat breakfasts that are very rich in sugar and, with everything we eat, if we avoid consuming any more it’s better. Beyond some presence of fructose or other excipients of the active ingredient of the drug that promotes its absorption, I would avoid sugar. A little water is enough”, smiles Alberto Corsini, full professor of pharmacology, University of Milan. A joke, his, but he introduces a very serious topic: there are many mistakes that people make when dealing with capsules and tablets. The most frequent one? Swallowing the pill without water, the expert explains to Adnkronos Salute.
“It’s true, we have orosoluble formulations that allow administration without the use of water – the pharmacologist begins – But let’s think about chronic patients, with high blood pressure, high cholesterol, diabetes: most therapies require drugs that require intake with water. Because otherwise we don’t absorb them”. And “a finger of water is not enough – he warns – you need a full glass, which means 150-200 ml, to promote solubilization and transfer to the gastrointestinal level, where the actual absorption then occurs. There have been many studies for 40-50 years now, which have shown that if I take the same aspirin, an antibiotic, any drug with a little water, rather than with a full glass, I absorb less than half. So I already have a therapeutic failure. Before even starting the treatment, I’m doing it wrong”.
The absorption of a drug is a very critical point, Corsini points out. In the ‘etiquette’ of oral drugs, it should be added that “it should be taken in an upright position”, trying at least to sit, in a vertical position and not lying down. “Because this favors the transfer from the mouth to the stomach by gravity. The passage in the esophagus takes about 2-3 minutes. In the space of 10 minutes, staying in that position, the drug reaches the stomach where absorption can take place. This passage is facilitated by water, which increases the weight”. There are many examples, the expert assures. “Let’s think of bisphosphonate drugs for osteoporosis in the elderly, which are poorly absorbable: we must help them by taking them with water with very little salt. You cannot take the drug with a coffee, a tea, a juice, because otherwise very little of it is absorbed. And it’s no joke, because the patient risks fractures”.
Another important element is when it is indicated that the drug must be taken with food. “This means that you have to eat a meal – says Corsini – In fact, when the drug is studied to understand whether or not it is important to take it near or far from meals, it is evaluated with the so-called ‘continental breakfast’. It means with a certain amount of fat, milk, sugar, etc. So the patient must eat. A biscuit in the morning is not enough. This information is also written in the information leaflets, but the pharmacist can help with this”, recalling the correct methods of taking the drug when dispensing the drug to the patient. Then there is the chapter on supplements: “If a person wants to consume vitamins, rather than salts, magnesium, calcium, it is best to do so away from medicines. Let’s take the example of thyroid drugs (in Lombardy there are 700 thousand people who receive these replacement therapy drugs because they may be hypothyroid). If they are taken with supplements, half of them are absorbed. The advice is therefore to wait at least two hours before taking the supplements”.
A message is also for those who, terrified of drowning themselves with pills, chew them: “Apart from the fact that I believe there are few that taste good, you need to know that saliva has a different pH than the gastrointestinal one – says Corsini – For example: proton pump inhibitor drugs”, widely used for ulcers, gastritis and reflux, “need to be in an acidic environment to be activated. If you chew them in your mouth, you end up losing them”. In short, if it is indicated that a drug should be taken in a certain way, “it is because it was studied in those conditions. A first aspect that is evaluated is the type of administration. And therefore the intake must not be done ‘ad personam’, but following the instructions”.
The list of the most common errors includes the choice to accompany the pills with milk. Here too the danger is just around the corner, because “many drugs, some antibiotics and other molecules, ‘precipitate’ with calcium, with dairy products. And so, once again, there is a therapeutic failure”, warns the pharmacologist. If “we don’t want to harm ourselves”, he continues, we obviously avoid washing the pill down with alcoholic beverages. “Alcohol solubilizes the molecule differently and that’s not good at all. The intake of the drug must be respected”. The examples are endless: “For some molecules, orange juice could lead to precipitation, it could lead to chelation – lists Corsini – Let’s take the example of some antibiotics, quinolones, rather than bisphosphonates”. We therefore risk “losing a large share of the success of therapies due to these very banal errors”.
Grapefruit juice deserves a special mention: “It was seen, several years ago, that the intake of significant quantities of grapefruit could inhibit the metabolism, the elimination of the drug, and this led to an increase in concentrations up to toxic effects. First it was seen with some antihypertensives, therefore with drops in blood pressure levels, then with a greater antiarrhythmic effect, greater problems of tolerability of cholesterol drugs. So much so that in hospital, in diets or in clinical studies, grapefruit has been banned. But this does not mean that I should not consume a glass of grapefruit juice a day. Things need to be contextualized: grapefruit is a powerful inhibitor of drug metabolism if you consume a liter a day. So drinking a glass in the morning and then taking a drug in the evening is not dramatic, except for very rare exceptions, such as some statins”.
Stimulants like coffee? “Telling an Italian not to drink coffee is impossible – he smiles – but even in this case, it is simply better to do it away from taking medications. The ideal strategy could be to take your medication with a large glass of water and then after half an hour or an hour have breakfast. These are simple suggestions that can help. The last important indication is that there are some medications, the famous old anticoagulants, for which you need to be careful to use vitamin K, which can be found in supplements, for example. So if you take warfarin – and in Italy there are still 400 thousand patients who take it – the supplement, if you really want to take it, must be taken at least two hours later. Those who take anticoagulants must then be careful to use vegetables with large leaves, which are rich in vitamin K. Obviously you can have a meal with salad, because everything must be contextualized. Medicines – concludes Corsini – help us but must be respected. Because if we do not take them according to the instructions, the risk is that they do not work. And you shouldn’t be afraid to ask the pharmacist, doctor or nurse what the correct rules are.” With all due respect to Mary Poppins.
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