Dangers of Mixing Alcohol with Certain Medications or Diseases

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Most U.S. adults drink alcohol at least occasionally, so it is not surprising that at one time or another most face questions about alcohol consumption while taking medications: Is it necessary to completely abstain from alcohol, or should you just moderate your alcohol intake? Should you only worry about alcohol-drug interactions if you are going to drive? If the prescription bottle does not have a warning label about alcohol, is it safe to drink alcohol while taking that drug?

The answers to these questions, of course, depend on many factors such as the specific medications in question, the diseases you have and the amount of alcohol you are planning to drink, as well as your age and general physical condition. Although some of the interactions between alcohol and medications mainly occur in people who drink heavily (three or more drinks on one occasion), many of these interactions may occur with much lower amounts of alcohol use, such as one to two drinks on an occasion.

We strongly urge you to tell your physicians and other health care providers how much alcohol you are drinking so they can effectively assess the risks and advise you about the safe use of alcohol and medications.

In this article, we will present some specific information as well as general guidelines to help you sort through these issues.

How does alcohol interact with medications?

Alcohol is itself a drug and medications, including alcohol, can interact with each other in several ways (some combinations of medications and alcohol may similarly interact by more than one of these mechanisms):

  • Medications Increasing Alcohol Blood Levels Several drugs including some anti-ulcer drugs (see below) can impair alcohol metabolism thus resulting in higher blood alcohol levels.

  • Additive effects. One of the best- known drug-alcohol interactions is when alcohol, a depressant, is taken with other sedative medications, and excessive sedation or depression of respiration can occur. Depending on the doses of the sedative and alcohol, these interactions can be life-threatening or fatal. For instance, people combining alcohol and sedatives can experience falls or other serious accidents, or unwittingly take a lethal cocktail of sedative medications and alcohol.

  • Alcohol effects on disease. Alcohol may interact with medications indirectly by adversely affecting the symptoms of the disease for which the medication is being used or by directly changing the effectiveness of drugs being used to treat the disease. For example, excessive alcohol use can be detrimental for patients with psychiatric disorders such as depression, bipolar disease and psychoses but may also reduce the effectiveness of medications used to treat these disorders. Other diseases in addition to psychiatric disorders adversely affected by alcohol include hypertension, diabetes mellitus, upper gastrointestinal conditions, gout, insomnia, depression, and cognitive impairment such as Alzheimer’s disease.

  • Alcohol increasing medication blood levels. The body considers alcohol and other drugs foreign chemicals that need to be eliminated. Like most other drugs, therefore, alcohol is metabolized by some of the same enzymes in the liver and elsewhere that allow the body to rid itself of the offending chemicals. Sometimes alcohol can overwhelm the drug-metabolizing machinery and the body is not able flush out the foreign chemicals well, which leads to elevated blood levels of medications and increased risk of toxicity blood levels.

  • Alcohol also can reduce blood levels of some medications. This occurs when a person has chronically ingested moderate to large amounts of alcohol, and the alcohol has increased the drugmetabolizing enzymes into "turbo" mode. So when a chronic alcohol user takes some medications, the effect of those medications will be reduced as the enzymes rapidly process the medication. In other words, the medication’s effect is reduced because the enzymes process and help to get rid of the medication too quickly.

What types of medications interact with alcohol?

While the more important alcohol-medication interactions are listed in the table, it is not an exhaustive list, so be sure to check with your health professionals before taking alcohol with any prescription or nonprescription drug.

What You Can Do

With reasonable precautions and common sense, it is possible to substantially reduce the risk of alcohol-medication interactions. The easiest way to avoid the problem is to simply stop drinking alcohol while you are taking medications, especially if the use of the medication is short-term. However, if you do choose to drink, pay particular attention to the specific drugs in the table and reading the instructions on your drug labels.

Sometimes people do not read the alcohol warning until they have already taken a medication for a week or two, and they have seen no problems with their glass of wine with dinner. This may cause them to wonder if the alcohol warning is overkill. The truth is that for most medications, a small glass of wine with dinner is not likely to cause problems. It is better to be safe than sorry, however, so if you want to have some alcohol, you need to go through the work of determining if it is okay. Here are some suggestions:

  • Read all of the information you receive from your physician or pharmacist about the prescription medications you receive. If alcohol is a problem, it will usually be mentioned.

  • Read the warning labels on the medication bottle; if it says not to drink alcohol, don’t. But the absence of an alcohol warning sticker on the bottle is not an absolute guarantee that it is okay to drink alcohol.

  • For nonprescription medications, read the label on the box carefully for any alcohol warnings.

  • If you have access to the Internet, you can usually find the needed information about combining alcohol with both prescription and nonprescription medications. The FDA Web site offers this type of information. Visit http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfm, where you will be able to search for your drug by either generic or brand name. For most drugs, the drug label with alcohol interaction information is available.

  • If you have any questions, ask your health professional.

 Drug or Drug Group

 Comments

  Acetaminophen (TYLENOL)

  • Can increased the risk of liver damage due to formation of toxic metabolites of acetaminophen.
  • If you regularly take 2-3 or more drinks per day, consult your physician before taking acetaminophen.
  • Watch for acetaminophen in combination prescription or nonprescription products

   Acitretin (SORIATANE)

  • Alcohol may cause conversion of acetretin to etretinate, which can cause birth defects and can last a long time in the body.
  • Women should completely abstain from alcohol while on acetretin and for two months after stopping acetretin therapy.

Antibiotics ("Antabuse" reac- tion, causing unpleasant side effects because alcohol cannot be digested)
Cefamandole (MANDOL) Cefoperazone (CEFOBID)
Cefotetan
Ceftriaxone (ROCEPHIN)
Furazolidone (FUROXONE)
Griseofulvin (FULVICIN, GRIFULVIN V, GRIS-PEG, GRISACTIN)
Ketoconazole (NIZORAL)
Metronidazole (FLAGYL)**
Quinacrine (ATABRINE)
Tinidazole (TINDAMAX, FASIGYN)

  • Antabuse reaction: Possible flushing, nausea, vomiting headache can occur after alcohol because of alcohol metabolites.
  • Reaction not consistent, but avoid alcohol to be safe

Antibiotics (Decreased levels)
Doxycycline (VIBRAMYCIN)** Erythromycin ethylsuccinate

  • Chronic ingestion of excessive amounts of alcohol may reduce doxycycline blood levels.
  • Acute ingestion of alcohol modestly reduced blood levels of erythromycin succinate effect on other erythromycins not established.

 Anticoagulants Warfarin      (COUMADIN)

  • Acute alcohol intake can increase anticoagulant effect of warfarin
  • Chronic alcohol abusers may have reduced effect of warfarin (when they are sober)

Antidepressants, MAO Inhibitor Phenelzine (NARDIL)
Tranylcypromine (PARNATE)

  • Some wines and beers containtyramine, a substance that can cause dangerous hypertensive reactions when combined with MAO inhibitors
  • Follow dietary and alcohol restrictions carefully

Antidepressants, SSRIs
Citalopram (CELEXA)**
Escitalopram (LEXAPRO)*
Fluoxetine (PROZAC, SERAFEM)** Fluvoxamine (LUVOX)**
Paroxetine (PAXIL, PEXEVA)** Sertraline (ZOLOFT)**

  • In general, SSRIs have little effect on the sedative effects of alcohol but alcohol alone can worsen depression, thus rendering these drugs less effective.

Antidepressants, Tricyclic Amitriptyline (ELAVIL)*
Amoxapine (ASCENDIN)** Clomipramine (ANAFRANIL) Desipramine (NORPRAMIN) Doxepin (SINEQUAN)**
Imipramine (TOFRANIL, TOFRANIL PM)**
Nortriptyline (AVENTYL, PAMELOR) Protriptyline (VIVACTIL)
Trimipramine (SURMONTIL)

  • Additive sedative effects, more with some tricyclic antidepressants than others.
  • Especially dangerous with driving or performing other tasks requiring alertness.
  • Alcohol alone can worsen depression, thus rendering these drugs less effective.

Antidiabetic medications Acetohexamide (DYMELOR)* Chlorpropamide (DIABINESE)* Glimepiride (AMARYL)** Glipizide (GLUCOTROL)** Glyburide (DIABETA, GLYNASE,    MICRONASE)**
Metformin (GLUCOPHAGE)** Nateglinide (STARLIX)*
Pioglitazone (ACTOS)*
Repaglinide (PRANDIN)* Rosiglitazone (AVANDIA)* Tolazamide (TOLINASE)** Tolbutamide (ORINASE)**

  • Excessive alcohol may result in severe hypoglycemia in diabetics, especially if they are fasting.
  • Some long-acting oral antidiabetic drugs can cause a reaction after alcohol (flushing, nausea, headache) effect may be reduced with chronic intake of moderate to large amounts of alcohol.

Antihistamines, sedating Azatadine (OPTIMINE, TRINALIN) Azelastine (ASTELIN)* Brompheniramine (DIMETANE) Carbinoxamine
Cetirizine (ZYRTEC)** Chlorpheniramine (ALERMINE, CHLOR-TRIMETON)
Clemastine (TAVIST-1) Dexchlorpheniramine (POLARAMINE) Diphenhydramine (BENADRYL, DYTAN SUSPENSION, DYTAN-D SUSPENSION, SOMINEX FORMULA) Hydroxyzine (ATARAX, HY-PAM, VISTARIL)
Levocabastine (LIVOSTIN)
Promethazine (PHENERGAN)** Tripelennamine (PBZ)
Triprolidine

  • Additive sedative effects; more with some sedating antihistamines than others.
  • Especially dangerous with driving or performing other tasks requiring alertness.
  • Nonsedating antihistamines may reduce risk.

Antipsychotic drugs
Chlorpromazine (THORAZINE)
Clozapine (CLOZARIL)
Quetiapine (SEROQUEL)
Thioridazine (MELLARIL)
Ziprasidone (GEODON)

  • Additive sedative effects with certain antipsychotic medications
  • Especially dangerous with driving or performing other tasks requiring alertness
  • Excessive alcohol ingestion may complicate treatment of psychoses

Antiseizure drugs
Carbamazepine (CARBATROL, TEGRETOL)
Clonazepam (KLONOPIN)
Divalproex (DEPAKENE/DEPAKOTE)
Gabapentin (NEURONTIN)**
Phenobarbital (LUMINAL, SOLFOTON)**
Phenytoin (DILANTIN)
Pregabalin (LYRICA)*** (2012)
Valproic acid (DEPAKENE)

  • Additive sedative effects with some antiseizure medications
  • Especially dangerous with driving or performing other tasks requiring alertness Acute alcohol ingestion may increase phenytoin (DILANTIN) levels, but chronic alcohol ingestion may decrease phenytoin when patient is sober

Antiulcer drugs
Cimetidine (TAGAMET)
Nizatidine (AXID)
Ranitidine (ZANTAC)

  • Excessive alcohol may worsen ulcers Increase in blood alcohol with cimetidine (TAGAMET), nizatidine (AXID) and ranitidine (ZANTAC)

Blood Pressure Drugs
Methyldopa (ALDOMET)
Clonidine (CATAPRES)*
Doxazosin (CARDURA)*
Prazosin (MINIPRESS)*
Terazosin (HYTRIN)*

  • With alcohol, there can be a dangerous exaggeration of the tendancy of the drugs to reduce blood pressure resulting in dangerous hypotension.

Chemotherapy

  • Alcohol may be off limits : because of its interaction with cancer drugs; check with your physician

Metoclopramide (drug for      nausea)

  • Possible increased effect of alcohol; limit alcohol intake

NSAIDs and Aspirin
Buffered aspirin (ASCRIPTIN, BUFFERIN)
Celecoxib (CELEBREX)
Diclofenac (VOLTAREN)
Diflunisal (DOLOBID)
Etodolac (LODINE)
Fenoprofen (NALFON)
Flurbiprofen (ANSAID, OCUFEN); Ibuprofen (ADVIL, MEDIPREN, MOTRIN, NUPRIN)
Indomethacin (INDOCIN) Ketoprofen (ORUDIS)
Ketorolac (TORADOL)
Meclofenamate (MECLOMEN) Mefenamic acid (PONSTEL)

  • Icreased stomach and intestinal bleeding because alcohol increases the tendency of aspirin and other NSAIDS to cause bleeding on their own.
  • Avoid aspirin and NSAIDs as a hangover preventative
  • Aspirin may increase blood alcohol levels, but the clinical importance of this effect is not clear

NSAIDs and Aspirin cont.
Meloxicam (MOBIC)
Nabumetone (RELAFEN)
Naproxen (ALEVE, ANAPROX, NAPROSYN)
Oxaprozin (DAYPRO)
Piroxicam (FELDENE)
Rofecoxib (VIOXX)
Salsalate (DISALCID)
Sulindac (CLINORIL)
Tolmetin (TOLECTIN)

  • Increased stomach and intestinal bleeding because alcohol increases the tendency of aspirin and other NSAIDS to cause bleeding on their own.
  • Avoid aspirin and NSAIDs as a hangover preventative
  • Aspirin may increase blood alcohol levels, but the clinical importance of this effect is not clear

Opioid analgesics (narcotics) Codeine
Meperidine (DEMEROL)
Morphine
Propoxyphene (DARVON)
many others

  • Additive sedative effects; can be life- threatening
  • Especially dangerous with driving or performing other tasks requiring alertness Increased risk of death if opioid and/or alcohol taken in overdose
  • Additive sedative effects; can be life- threatening

Sedatives, Hypnotics, Tranquillizers
Alprazolam (XANAX)*
Chlordiazepoxide (LIBRIUM)*
Clorazepate (TRANXENE)*
Diazepam (VALIUM)*
Estazolam (PROSOM)*
Flurazepam (DALMANE)*
Halazepam (PAXIPAM)*
Lorazepam (ATIVAN)*
Oxazepam (SERAX)**
Prazepam (CENTRAX)*
Quazepam (DORAL)*
Temazepam (RESTORIL)*
Triazolam (HALCION)*
Zaleplon (SONATA)**
Zolpidem (AMBIEN)**

  • Epecially dangerous with driving or performing other tasks requiring alertness
  • Chronic heavy drinkers may get decreased effects from benzodiazepines such as diazepam (VALIUM) because they get rid of them too quickly but episodic, binge drinkers may not get rid of the drugs quickly enough and can get toxic effects.

Tizanidine (ZANAFLEX)

  • Additive sedative effect and increased tizanidine blood levels
  • Caution with driving or performing other tasks requiring alertness

Vasodilators
Nitrates
Hydralazine

  • Possible increased risk of acute reduction in blood pressure (hypotension)

Verapamil (CALAN, CALAN SR, COVERA-HS, ISOPTIN, ISOPTIN SR, VERELAN)

  • Increased alcohol blood levels
  • Limit alcohol intake
  • May occur with some other calcium channel blockers such as nifedipine (ADALAT CC, PROCARDIA XL)

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