No, a little sugar is not enough to make the pill go down, as Mary Poppins, the unforgettable magical nanny from the cult Disney film, sang. “I don’t want to hurt a character who takes me back to my childhood, but we already have a very sugary breakfast and, with everything we eat, if we avoid consuming more, it’s better. Beyond some presence of fructose or other excipients of the active ingredient of the drug that favor its absorption, I would avoid sugar. A little water is enough,” smiles Alberto Corsini, professor of pharmacology at the University of Milan. A joke, his, but it introduces a very serious subject: there are many mistakes made when it comes to capsules and tablets. The most frequent one? Swallowing the pill without water, explains the expert to Adnkronos Salute.
“It is true that we have oral-soluble formulations that allow administration without the use of water,” the pharmacologist begins, “but let us think of chronic patients with hypertension, high cholesterol, diabetes: most therapies require medications that must be taken with water, because otherwise we do not absorb them.” And “a finger of water is not enough,” he warns, “a full glass is needed, that is, 150-200 ml, to promote solubilization and passage to the gastrointestinal level, where the actual absorption then occurs. There are many studies from 40-50 years ago that have shown that if I take the same aspirin, an antibiotic, any drug with a little water, instead of with a full glass, I absorb less than half. Then I already have a therapeutic failure. Even before starting the treatment, I am doing it wrong.”
The absorption of a drug is a very critical point, Corsini points out. On the label of oral drugs it should be added that “they should be taken in an upright position”, trying at least to sit upright and not lying down. “Because this favours the passage from the mouth to the stomach by gravity. The passage in the oesophagus takes about 2-3 minutes. In the space of 10 minutes, remaining in this position, the drug reaches the stomach where absorption can take place. This passage is facilitated by water, which increases weight.” There are many examples, says the expert. “Let’s think of bisphosphonates for osteoporosis in the elderly, which are poorly absorbed: they must be helped by taking them with water with very little salt. You can’t take the drug with coffee, tea, juice, because otherwise it is absorbed very little. And this is no joke, because the patient runs the risk of fractures.”
Another important element is when it is indicated that the medicine should be taken with food. “This means that a meal must be eaten – says Corsini – In fact, when the medicine is studied to understand whether it is important or not to take it close to or far from meals, it is evaluated with the so-called ‘continental breakfast’. That is, 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 leaflets, but the pharmacist can help in this”, recalling the correct ways of taking the medicine when dispensing it to the patient. Then there is the chapter on supplements: “If a person wants to consume vitamins, rather than salts, magnesium, calcium, it is better to do so away from medicines. Let’s take the example of thyroid medicines (in Lombardy there are 700 thousand people who receive these replacement therapy drugs because they can be hypothyroid). If they are taken with supplements, half of them are absorbed. Therefore, the advice is to wait at least two hours before taking supplements.”
A message also for those who, terrified of choking on pills, chew them: “Apart from the fact that I think there are few that taste good, you have to know that saliva has a different pH to the gastrointestinal tract,” 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 must be taken in a certain way, “it is because it has been studied under those conditions. A first aspect that is evaluated is the type of administration. And therefore the taking should not be done ‘ad personam’, but following the instructions.”
Among the most common mistakes is the choice to take pills with milk. Here too, danger is just around the corner, because “many drugs, some antibiotics and other molecules, are ‘precipitated’ by calcium, by dairy products. And then, once again, there is a therapeutic failure,” warns the pharmacologist. If “we do not want to harm ourselves,” he continues, we obviously avoid taking pills with alcoholic beverages. “Alcohol solubilises the molecule differently and that is not good at all. We must respect the dosage of the drug.” The examples are endless: “For some molecules, orange juice could cause a precipitation, it could cause chelation – lists Corsini – Let us take the example of some antibiotics, quinolones, instead of bisphosphonates.” We therefore run the risk of “losing a large part of the success of therapies due to such trivial errors.”
Grapefruit juice deserves a special mention: “It has been several years since it was seen that the consumption of significant quantities of grapefruit could inhibit the metabolism, the elimination of the drug, and this led to an increase in concentrations until it reached toxic effects. First it was seen with some antihypertensives, therefore with lowering of blood pressure levels, then with a greater antiarrhythmic effect, greater problems of tolerability of cholesterol drugs. So much so that in hospitals, in diets or in clinical studies grapefruit has been banned. But this does not mean that you should not consume a glass of grapefruit juice a day. Things need to be put into context: grapefruit is a powerful inhibitor of drug metabolism if you consume a litre a day. So drinking a glass in the morning and then taking a drug at night is not dramatic, except in 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 better to do so without taking medication. The ideal strategy could be to take the 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 have 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, should be taken at least two hours later. Those who take anticoagulants should be careful to use large leafy vegetables, which are rich in vitamin K. Obviously you can eat it with salad, because everything must be contextualized. Medications – concludes Corsini – help us, but we must respect them. 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, the doctor or the nurse what the correct rules are.” With all due respect to Mary Poppins.
