Did you know that in addition to the active ingredients in a drug, its excipients can also greatly impact a patient’s nutritional health or cause side effects? With more and more patients being prescribed multiple medications it’s becoming increasingly important for every practitioner to have resources to help identify potential interactions.
Today we are joined by Yvonne Coleman, a dietitian specialising in aged care who has investigated and created a vast compendium of drug-nutrient interactions for practitioners. She takes us through some of the issues in determining what these interactions might be, such as the limitations of pathology testing, as well as some of the most common drugs that affect nutritional status.
Covered in this episode
[00:49] Welcoming Yvonne Coleman
[01:49] What sparked Yvonne’s interest in drug-nutrient interactions
[05:33] The issues with measuring nutrients through pathology testing
[10:45] Vitamin D serum levels
[12:55] Proton Pump Inhibitors and drugs that impact nutrient absorption
[19:25] The creation of the drug-nutrient interaction charts
[22:28] Caffeine’s effect on pain medication
[23:54] Iron’s effect on thyroxine and levodopa
[25:51] Administering drugs to patients who have trouble swallowing or are on a feeding tube
[28:23] Excipients and how the change the pharmacodynamics of the drug
[33:38] Additional resources
[36:52] Thanking Yvonne and closing remarks
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us on the line today is Yvonne Coleman, who's worked as a dietitian for more than two decades in aged care, initially in the public health sector, and more recently, as founding principal of Nutrition Consultants Australia, a consultancy that specialises in nutrition for the elderly.
Yvonne's broad experience extends to being a chief dietitian with development and supervisory roles in the public health system, state government Enteral Nutrition Working Party involvement, community radio appearances, and presenting research at both national and international conferences on a range of nutritionally related topics.
She has published several books in the area of elderly nutrition, particularly relating to drug-nutrient interactions, and that's what we'll be discussing on FX Medicine today.
Welcome, Yvonne Coleman. How are you?
Yvonne: Wonderful. Thanks, Andrew. And thank you for inviting me.
Andrew: It's my pleasure. Now, I can't remember how I first found your fold out, I do not remember it. But it's become integral in making sure that we're taking care of patients. We'll delve into that in a second.
But I first want to delve a little bit into your career, and how you settled on your interest, your avid interest of drug-nutrient interactions, where did this all start?
Yvonne: In the '80s and '90s, I would go to conferences, and they would say… and of course, they would be talking about malnutrition, or compromised nutritional health and of course, drug-nutrient interactions and move on to the next stop point. And no one ever expanded that point. No one ever gave examples. This is at the top conferences. And I got curious.
Then in the early '90s, I was working in aged care and rehab and I had people on my books who were prescribed 20 different drugs. And they had poorly controlled diabetes, and I started to ask what was the impact of those drugs on their nutritional health? And with diabetes, I was particularly curious about chromium.
Yvonne: And I couldn't find any literature. It was just impossible to find anything beyond drug-nutrient interactions as a dot point, or at a conference presentation. It was really difficult finding examples, and certainly not anything that I could use as a clinician. And then I stumbled across a paper, and they had examples. So that became the basis of it and I said to my staff, "Right, we're going to integrate this into our clinical practice."
And of course, the first question was, "How do we take this information and present it?" Which we trialed different ways, and we came up with a table format that seemed to work best for us. And in that table format, we actually had what I called Drug-nut labels drawn up and you would write in the drug name, the nutrients affected and then tick off the key side effects like nausea, vomiting, constipation, diarrhoea, changes to appetite, weight, taste.
And I always included drooling because drooling doesn't happen very often. But when it does, dehydration, that's a profound issue, and impact on blood sugars.
Andrew: You know what? I've never even contemplated that.
Yvonne: Impact on blood sugar?
Andrew: Drooling. Yeah.
Yvonne: Oh, drooling? Yeah. And some of that came out because I was also really quite interested in tube feeding. In the '90s tube feeding was really quite predominant in elderly people. And in the young people, drooling can be a major issue and they can be losing litres a day, pouring over their lower gums, down their chin.
Yvonne: And it was more about how do you manage the redness on their chin? Because of these salivary enzymes impacting on the skin. So it was a sideways interest and I thought, "Well, drooling's really important when it's there. It's really important." So I integrated it into that check sheet as well.
Andrew: I never even contemplated it and its effect or its impact on a fluid balance chart. Never even thought about it.
Yvonne: No. And they lose litres a day.
Andrew: Yeah. You said something about chromium though just first, is one of these real issues with regards to why nutrients aren't mentioned, is one of the main issues because they're hard to measure?
Yvonne: Yes. And the hard to measure is for a couple of reasons. The first reason is nutrients like chromium are right on the edge of measurability with our current technology. When I was looking at it in the '90s it was right on the edge of being able to be measured and people didn't think of chromium as a nutrient, they thought of it as a toxin. And think of that film starring Julia Roberts.
Andrew: Yes. Brockovich, Ellen Brockovich.
Yvonne: Yes. So the chromium in that was the toxic form which is six plus, but there is also a biological form which is three plus, but it's right on the edge of being measured and that's the problem with things like chromium, and selenium, and some of the other things we just don't hear about.
The other issue is pathology lab ranges. And the pathology lab ranges don't always reflect research findings and a really classic example for that would be vitamin B12 and vitamin D. So when you look at the research, what are the test ranges? What ranges are they actually using to draw their conclusion?
Last year there was a fantastic neuro-imaging study that has found there is change to brain structure and function once B12 levels drop below 300 picomoles per litre. Well, the pathology ranges in Australia are around 220, around that 220-ish still. Somewhere at 240. A lot of the research and because I've been looking at metformin and B12 a lot of the global research is looking at 150 as the cutoff point for deficiency and up to 220 for that mild deficiency, or borderline deficient. So...
Andrew: So what we would term as “adequate” is actually showing neurological degeneration?
Yvonne: Is already causing harm. And then years ago they decided that diabetic neuropathy was not due to inadequate B12. Well of course the ranges were so low and people would have been so low, that they wouldn't have been able to differentiate.
Yvonne: So now some of this cutting edge stuff I've been reading with regard to neurodegeneration in general is that they're starting to turn around and say, "You know, there's a lot of commonality between diabetic neuropathy and B12 deficiency and maybe we need to revisit this."
And the other classic one is vitamin D and the research was... the pathology labs up until two or three years ago the vitamin D levels were edging up with a lower cutoff point of 75 picomoles per litre. And then some men in New Zealand went and did a meta-analysis and just chose 15 picomoles per litre as the lower cutoff point. So the pathology labs couldn't get their ranges down to that range quickly enough, it was really hard getting them to get it up but they could drop them very quickly. And all this...
Andrew: Is it picomoles? This is nanomoles yeah? Nanomoles in vitamin D?
Yvonne: No, in moles. In moles. Sorry.
So now all the research is starting to say… and there was a fantastic meta-analysis that came out earlier this year and it said for bone health purposes having a lower acceptable limit of 50 or 75 nanomoles per litre is fine for bone health purposes. But if you're looking at the non-bone health implications of vitamin D, then a low vitamin D contribution to bowel cancer is 137 nanomoles per litre. So you've got to get your vitamin D levels up above 137 nanomoles per litre to reduce the vitamin D impact on bowel cancer.
Yvonne: And if you want to take the low vitamin D contribution to diabetes out of the equation you've got to get it up over 160. Well, I don't see very many people with vitamin D levels up over 160 and in fact the medical profession gets a little bit excited and say, "Oh, you've got to drop your vitamin D intake…
Andrew: Yeah. Crazy.
Yvonne: “…when it gets up there,” so there’s just no understanding. The pathology labs are nowhere near where the research is going, and they’re consistently getting these findings.
Andrew: I was speaking with Professor Holick, Michael Holick, some years ago, who was speaking about an African...forgive me, I'm going to say Kenyan tribesmen. But he was measuring things up around the mid-200s. There was paranoia, I would say, in Australia, regarding this J-Curve, that too much was as bad as too little. And so they were worried about where this J-Curve was going.
Because at that stage, people were getting quite heroic with dosages. Now, I think it was Jenny Gunton, at Westmead Hospital was giving deficient - forgive me if I have this wrong again - diabetics or pre-diabetics. She was giving them four to five thousand IU in pregnancy. And it's just really interesting how much vitamin D is needed to increase the serum level, once you have a low level because your body has these elegant protective mechanisms to basically destroy too much vitamin D. You have to way go over the upper limit of normal to actually massively affect the serum levels of vitamin D. But of course, the safe level is from sun, sensible sun exposure.
Yvonne: Well, the other thing is, once you've turned pink, you don't produce any more vitamin D anyway, it all shuts down.
Andrew: Yeah, that's right.
Yvonne: So the body's built in a fail-safe mechanism there. But in the '50s and '60s, sunbaking was such a standard part of the Australian life. And you look at all the diseases we didn't have, in the way we have now. You can look at mental health stuff and you can look at skin cancers, and you can look at a whole range of things. Because once vitamin D is too low, then of course there's increased risk of getting skin cancer as well.
Andrew: Yes, that's right.
Yvonne: And of course one of the other things is when the body levels are low, the body's tapping into its storage, and so you're depleting your storage levels as well. And so the body's desperate, also desperately trying to top up the stores.
Andrew: You mentioned earlier about nothing less than poly-pharmacy with that person on multiple medications. Indeed, I've run into the same experience where one lady was on 26 medicines per day. By the end of February, in beginning of March, she was on the free list in Australia, so forgive other countries. In Australia once you've reached 52 scripts the government subsidises it after that, particularly for pensioners.
And I couldn't handle this ethically. I worked in a pharmacy at the time, I was doing deliveries to this lady's home. I referred her to a physician or got her referred to a physician. And this lovely man put her into hospital and she came out on four medicines.
Yvonne: Well done. Congratulations.
Andrew: Well, congratulations. I will say to this man, to Dr. Quinn. He was brilliant. But what an issue of poly-pharmacy, nothing more than lazy medicine. But worse off, it was causing more and more compounding and compounding nutritional interactions.
Yvonne: Oh, I have some favourites.
Andrew: Well, and this is indeed where your work has led you isn't it?
Yvonne: Yes, it has. So I have a group, a class of drugs I absolutely hate. And that's the proton pump inhibitors, or the acid inhibitors in general and the proton pump inhibitors in particular, because they reduce gastric acidity. And I don't know why - and I'm talking about the elderly here - why a cohort or a population group that are already producing less gastric acidity because of the ageing process, are then given acid inhibitors.
Andrew: Because it's a symptom relief.
Yvonne: So there's even less acid there to digest the food. Of course, then things like all the nutrients are not being converted to the absorbable form. And so I suspect this ongoing malnutrition that no one is monitoring, but it is known that proton pump inhibitors impact on B12 status, vitamin C, magnesium, zinc, iron, and indirectly through magnesium and thiamin.
Andrew: Oh, and then we worry about their mental health, their dementia, deterioration.
Yvonne: Well, they don't associate that with the proton pump inhibitors. One of the big things with the proton pump inhibitors is very small protein peptide chains can be absorbed where there’s two or three amino acids. And because there's not the complete digestion, these small peptides are being absorbed and it's leading to potential anaphylaxis, an allergy at the same level of peanut allergy, which can result in anaphylaxis.
Andrew: Ah, right. Yeah.
Yvonne: Now, when we start getting anaphylaxis in nursing homes, no one is going to turn around and say, "It's because they've been taking a proton pump inhibitor for more than five years." They're going to say, "I wonder what environmental," as in physical environment, not drug environment, "environmental impact caused this." So they're just not going to point the finger at proton pump inhibitors.
But then of course, the proton pump inhibitors are quite often prescribed with Metformin, being a diabetes agent, anti-diabetes agent. And Metformin has been known since the 1960s, that it drops B12. And the literature has been consistent through all those decades, Metformin drops B12. And it's still not part of the clinical recommendations to monitor B12 on a regular basis.
Yvonne: Well, that is the question.
Andrew: Why is this ignored? I don't get it.
Yvonne: No, me either. So you've got your proton pump inhibitor and your Metformin, and the research is now saying when you put proton pump inhibitors together with Metformin, there is an additive impact on B12 levels. So that's one of my favourites.
And the other one is, it's people on a proton pump inhibitor, they're probably prescribed furosemide. Furosemide is a diuretic, and it increases the loss of magnesium. Proton pump inhibitors decrease the absorption of magnesium. So I call that the Daily Double. And I actually write in my reports, “Currently prescribed the Daily Double.”
Yvonne: Then, of course, there's the trifecta. And the trifecta is your proton pump inhibitor, plus furosemide, plus digoxin. And both furosemide and digoxin increase urinary loss of magnesium. And it's the people on the trifecta who are more likely to end up in intensive care, and they may or may not come out. And it was through the intensive care department, the case studies - and it was an Australian team that led this - that started writing the case studies on proton pump inhibitors dropping magnesium levels.
Andrew: Now, it's interesting you say that with regards to magnesium and digoxin, because the very old study the LIMIT-1 or studies, LIMIT-1, LIMIT-2, they used magnesium in an emergency situation to rescue people with an AMI or acute coronary syndrome, ACS. They rescued people in an emergency situation, whereas then the ISIS-4 trial came along and killed people.
And not just that, but they said, "By the way, magnesium doesn't work." But what they did is they gave it wrong. They gave it incorrectly. So it was given, I think it was too much of a bolus dose, too late, and too little frequency, too infrequent. Whereas they could have rescued them.
Yvonne: Yeah, the other thing with magnesium is, again, we come back to pathology lab ranges. And I've seen some pathology labs with a cut off at 0.7 units. And I've seen some was cut offs at 0.6. And I came across a paper earlier this year that saying we should be using 0.8. And I can't remember the unit as the lower acceptable limit for people on magnesium.
Andrew: Right. That's it...
Yvonne: That doesn't quite percolated through to pathology labs or doctors?
Andrew: No, but that's quite a difference when you think of to, you know, what are we talking about? 12%? 15%?
Yvonne: Well, if you're working on 60, it's 30%.
Andrew: Yeah, you're right. So I guess where we go from here is what you've developed. And this… I just find it invaluable, these drug-nut charts, particularly when people are on multiple medications, but also to flag something that might be of interest when you've got a symptom presenting.
So can you take us through… you've taken us through why you developed it, but can you take us through how they work?
Yvonne: Okay, thank you for the lovely compliment. When I developed... it used to be Drug-nutrient Interactions: the Manual and then in a fit of insanity, I changed the name to Medications and Nutrition: a Quick Reference for Busy Clinicians. The title is more relevant, but lots of people were so used to it being called Drug-Nutrient Interactions, I think I lost a few people at that point.
But I developed it for clinicians. I am a clinician and I wanted quick, easy access to the information. And as a clinician, I actually have less concern as to whether the information is a case study or a huge trial. And a lot of this stuff, there won't be huge trials because there's no one with a vested interest in conducting huge trials.
Yvonne: So a lot of the research is small study stuff. But I wanted something that when I was looking at all these people and all these drugs, what were the nutrients I had to be concerned about? And what was their commonality?
So as I said, I've got the Daily Double, and the trifecta and few others that I comment on so that I can create an awareness. So I just put everything in, I thought, "Oh, I better identify which are case studies and which are…” I don't put in animal studies. Unless it's really, really profoundly shocking. But I'll put in pretty much everything else. I referenced absolutely every entry so that people can go back to the research and draw their own conclusions.
But I wanted to place, a one-stop place where people could go and get good quality research, or what is being published in the research in one place. And so that was the basis of it. And I looked at those drugs' impact on blood sugars, do they impact on thyroid? Do they impact on cholesterol levels? Then I looked at drug food interactions, good old grapefruit comes up, then Atenolol and apple juice is another one, or...
Andrew: Apple juice?
Yvonne: Yes. And it's through the transporters in the gut.
Yvonne: There's an interaction between the transporters in the gut between Atenolol and apple juice. And looking at things like licorice, caffeine.
A lot of people when they have a headache, they take two paracetamol with a cup of tea or coffee and have a good lie down. Well, of course, dietary levels of caffeine, as in the amount of caffeine in a cup of tea or coffee, reduces the pain management effect of paracetamol. So in a lot of cases, it's probably the good lie down that's conferring the most benefits.
Andrew: Now I've got a question that, because I thought that caffeine was used as a transporter for paracetamol. I thought that was the new kid on the block. They've got different amino acids, and they're using caffeine to assist in the use of paracetamol. Not the case?
Yvonne: Don't know about that. High dose caffeine intake, as in really high dose caffeine intake, is actually associated with enhancing the pain management effect of the drugs that it's been coupled with. And now a whole lot of pain management drugs, are in combination with caffeine.
Andrew: That's it.
Yvonne: So it's that high dose caffeine that enhances the pain management effect. With dietary levels, we're talking about the daily intake of cups of tea and coffee, that actually reduces paracetamol effects.
Andrew: Wow. So it's going to be a nociceptive effect.
Yvonne: Yeah, so I looked at drug-food stuff. And then I looked at drug-nutrient interactions. So what impact is the drugs having on these nutrients? What impact is the nutrients having on these drugs?
So we've already talked about proton pump inhibitors reducing magnesium absorption and furosemide increasing magnesium loss. But if you administer iron with thyroxine, it reduces the availability of both the iron and the thyroxine. So, if someone's feeling tired, or, they're thinking, "Oh, I'm probably a bit low in iron." And so they travel down to the supermarket and they buy their iron tabs, and everyone takes their tabs at the same time, and that's typically after breakfast.
So down goes the thyroxine and down goes the, and of course the other one is levodopa… down go the drugs and down goes the iron. All at the same time. And of course the control for their thyroid or their Parkinson's deteriorates and of course the response is, "Well you have a disorder.” No one, absolutely no one asks, "Have you made any changes? Have you started to take any vitamin or mineral tablets?"
Andrew: It's a really important question isn't it? Change.
Yvonne: It's a really important question. Then of course, the person still feels tired and they stop taking their iron or they've run it out and they've decided it's not making any difference. By this time, the doctors fiddle with the drug doses to try and improve, to stabilise the condition. And of course, all of a sudden, once the iron is stopped, then they become over medicated.
Yvonne: It's just so profoundly important to ask the question, “Have you started to take any over the counter tablets?”
Then I also decided people with swallowing problems ought to be included because administering drugs to people with impaired swallow reflex is a real problem and can change the drug dynamics. So people then mix a whole lot of drugs up together and gives them with a range of different foods, ice cream, custard, yoghurt, applesauce, whatever is in the fridge that’s in a liquidy form and they mix it all up. And of course, each of those food stuffs changes the dynamic of the drugs once they hit the stomach for digestion.
It's really important for anyone with an impaired swallow reflex who is mixing their drugs into a foodstuff to improve their ability to swallow it, that they use the same food stuff all the time.
Andrew: Of course.
Yvonne: And of course, quite a few years ago, there was some research looking into this in South Australia, and they found plain yoghurt was the best. A lot of people don't like plain yoghurt. So a lot of people use an applesauce. Provided they use that same foodstuff every day, then the dose intake is stabilised.
Then I looked at people on tube feeds, and I thought, "Oh, well, changing the drug and pumping it down that tube." So I looked at the government administration in relation to tube feeds, and that's really under researched area, because in reading some of the research articles, it's actually not clear whether they pop the drug into the bag of formula to administer, which is a big, big, big, big no-no.
And therefore, what is the time-frame between stopping the tube feed, having a gap, administering the drug, having a gap before starting the tube feed again? So with warfarin, the time-frames can be anywhere between one and three hours, you know? You stop your feed three hours before you give your warfarin, and then you start you feed three hours after you've given the drug. Well that's six, to eight hours out of maybe 15 hours...
Andrew: And you wonder why they don't know how many hours have gone.
Yvonne: Well, if they don't comply, then it's really hard to get the food down. They should just give it slowly. So I put all that stuff in.
And then for a long time, I've been putting in the ingredients wrapped around the drugs. And then of course the ingredients in drugs have a different name, they're called excipients. And so I was looking at gluten, and lactose, and galactose, and the colours, and flavours, and alcohol, and...
Yvonne: Yes, whether… and I was looking at medical, philosophical, cultural, religious demands. So did they contain pork? Did they contain beef? And of course, gelatin tabs are a big issue for vegetarians. So I was putting all that in. But over the years, I've realised that some of these drugs change owners like other people change their underwear, so I'm taking all that out. It's too hard to keep up with.
Andrew: Does the changing of any of these excipient or tableting aids, change the Pharmaco dynamics of the tablet or the medication?
Yvonne: Yes, it does. And I was just reading about this this weekend. An example of that is magnesium aspartate. Magnesium aspartate, is quite..., I think it's aspartate.
Andrew: A stearate. Stearate?
Yvonne: Magnesium stearate is actually quite often an excipient, or an ingredient packed around the drugs. And I was reading this week that there's an interaction between the active drug and the magnesium stearate. So if you suddenly have companies making that drug available without the magnesium stearate you're going to have a very different effect from companies making it available with the magnesium stearate.
Andrew: Yeah. It was really interesting because in the nutritional supplement industry, there was one camp, if you like, that said, "Oh, this stuff's really bad and we shouldn't be using it and things like that." And yet I seem to recall a study, I think it was atenolol, where it actually improved the absorption.
Yvonne: Yeah. So I understand it, when the patents come out on these drugs, they really have to balance administration in relation to food. And food in the pharmacy industry is only ever to modify side effects, it's not for any other reason.
So can they administer the drug on an empty tummy, which enhances the absorption or must they administer it with food to minimise side effects? And so they go through that whole process. Once the drugs come off patent, those same excipients are not necessarily wrapped around that drug, and therefore the drug with the copycat manufacturers will have an increased risk of reacting slightly differently.
Andrew: Yeah, and I think this is really interesting. There was a young pharmacist who then went on to do medicine, but one of her assignments was basically around the absorption and indeed, the area of the curve of drugs.
Now, given that this was decades ago, so this may not be correct, but what they found is that it wasn't the area under the curve that was the issue, it was the shape of the area under the curve. So for instance, we would commonly get people that would prefer a generic or prefer the trade name drug, the original drug. And it's because it worked better for them. And that may be because of, placebo absolutely, but it also might be because that person got a better effect from that drug, depending on the shape of that curve.
Yvonne: And which could have been influenced by the excipients.
Andrew: Excipients, food. A whole lot.
Yvonne: Yeah. So those are the different headings that I've put into the manual. And I have a number of journals, like about 50 or 60 coming across my desk every week and I get an email table of contents and file off everything of interest. And then I toddle off and pull as many references as I can and then I sit down, and I'll have to read them. And this year’s effort came up to my knee. They’re not all in.
Andrew: Now, I do love your work, but I have to ask, do you find that this issue of poly-pharmacy, do you mainly find that your work impacts on elderly patients? Or do you find younger and younger people taking more and more medications, and having nutritional impacts on this?
Yvonne: I work in the aged care, so I can't answer beyond that. But certainly the staff I work with come from a lot of different walks of life. And as we're talking about the children, I'm hearing more and more about children who are taking, especially proton pump inhibitors from a very young age, and it looks like those kids aren't going to come off those drugs.
Yvonne: And if you think drugs that could be prescribed whole-of-life would be the anti-epileptics, and insulin. So now people can get diagnosed... And maybe even these days, some of the anti-psychotics, and I'm talking about kids like two, and three, and four, right through to being 70, and 80. They could be on those drugs all that time. So some of these drugs can be whole-of-life drugs.
Andrew: Yvonne, I love the way that you target each year, you target a class of drugs, and you get all of the information that's pertinent for drug-nutrient interactions, to help clinicians in managing these in their patients. And I want to give our listeners the resources so that they can grab a hold of these to use them in their clinic.
So I've always known of nutritionconsultantsaustralia.com.au. That's where I used to get like the favourite 50 and the big folder, I used to get the big folder. Now I understand that's moving online, is that right?
Yvonne: Everything is now online. And people haven't been interested in having the favourite 50 online, they've just been subscribing to the main database. And the database is $99 a year for a year's subscription, which is fairly very good value, I think.
Andrew: Oh, I think.
Yvonne: Yeah. So people can go online. Once I get...my big log jam has been websites and the way to go forward, whether I have one big one or separate ones. So now that I've decided to go down the path of separate ones, I'll be getting the database rebuilt and it'll have a whole lot more functions built into it. So people can download a whole lot of stuff and print off reports that they can then send to the GPs, or give it to their patients, or can keep for themselves.
Andrew: So will that have the drug-nut chart that I've used?
Yvonne: Yeah, there will be variations on the drug-nut charts. So people will have... Each page, people can click on and choose a drug, say furosemide, or the brand. And that will be a bit like MIMS, it's a drug to a page, or to a web page. And then we're hoping to be able to download some of the stuff into a label-type concept, so that you can see which nutrients are being affected and the common side effects and copy out the key points from the information that can be integrated into any report that wants to be sent off.
Andrew: Great. So these nutritionconsultantsaustralia.com.au is the existing site. And in the future there will be drugsandnutrition.com.au. And I understand drugsandnutrition.com as well, for our overseas listeners. Is that right?
Yvonne: That's correct. Yes.
Andrew: Fantastic. One last question, Yvonne before we go. And that is will you be having international names of drugs as well as the… obviously we're based in Australia, but will you be referencing things like acetaminophen versus paracetamol,
Yvonne: Australia is moving over to the international terminology.
Andrew: There we go.
Yvonne: So furosemide, will become furosemide. And I'll be moving across to that as well.
Andrew: That's fantastic. I’ve got to say, like I have found this invaluable, particularly when people are on multiple drugs. But as you say, even when there's serious side effects from the chronic use of a medication with regards to one nutrient, like for instance, you mentioned Metformin and B12. And also the PPIs.
I can't thank you enough for your service, and the help that you've given me in caring for patients, particularly as I say, multiple meds, it's been an invaluable resource. I hope people really latch on to this and use it for helping their patients.
Yvonne: Andrew, thank you so much for those lovely compliments. And it's really heart-warming hearing that people do benefit from it, because I quite often hit my head against GP resistance. The thing is, if you look at the anti-epileptics, people have looked at people with diabetes, and they've said, "Oh yes, a subset of them go and get epilepsy." And I think they're looking at that the wrong way around.
A lot of the anti-epileptic drugs interfere with biotin absorption and its competitive inhibition. So there's a lot more of the drug around, and they share the same transporters. And so it just knocks biotin out of the way. And biotin is really important in energy metabolism.
So I think the question being asked, should be, "Do people prescribed long term anti-epileptics get diabetes?" And I think that's because that's where the mechanism is. There isn’t a logical mechanism going from diabetes to epilepsy, but there is from epilepsy to diabetes.
Andrew: Yvonne, thanks for joining us on FX Medicine.
Yvonne: Andrew, thank you so much for having me. It's been fun.
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.