by Tania Houspian, PharmD 2011
It’s inevitable and happens at least twice a month. Plans will be made to go out to a bar with friends and, as the first cocktail is being ordered, someone remembers that they’re on antibiotics for an infection they’d rather not talk about. The question is raised about whether or not it’s OK to drink alcohol with that particular medication. At that point, everyone turns to the friend with some form of medical training and asks, “So can I drink or what?” Members of the House Call, MD staff have experienced this so often we’ve started to avoid going out for drinks with infection-prone friends. What a loaded question! If the answer is, “No”, then the friend will spend the rest of the night pouting about not being able to drink and secretly blame the messenger for it. To avoid those awkward conversations, we’d like to take a moment and explain why sometimes it better to put the drinks aside when on certain medications. We apologize in advance for your drink-less night out.
Why does alcohol interact with certain medications?
Alcohol is broken down by two parts of your body: your stomach and your liver. When that shot of whiskey reaches the stomach some of the alcohol is broken down and the rest is absorbed into your blood stream. From your bloodstream, the alcohol is delivered to your liver via the portal vein. In the liver, about 10% of the remaining alcohol is broken down. The remaining alcohol is passed back into your bloodstream and is free to create all those magical affects alcohol has on your brain (i.e. thinking you’re a better dancer than you really are, being exceedingly friendly with strangers, etc.). At any of those stops that alcohol makes in your system (stomach, liver or brain) there is a possibility for it to interact with any medications that may possibly be taking the same path (1). Below we’ll go through different classes of medications, covering specific medications from each class and how they interact with alcohol.
Medications: Metronidazole, Nitrofurantoin, Tinidazole, Ketoconazole, Cycloserine, Cefoperazone, Cefotetan, and Griseofulvin
Just a shot of vodka along with any of these medications and you may be hugging the porcelain throne earlier in the night than you had planned. When mixed with alcohol, these medications can cause a violent reaction in your stomach called a “disulfiram-like reaction.” This reaction results in a sudden increase in heart rate, turning beet red, upset stomach, nausea, vomiting and, in worst case scenarios, death (2). Antabuse is the name of a medication whose main component is disulfram. When people want to quit drinking they are prescribed Antabuse so that if they do give in to their urge to drink they’ll have a violent reaction to the alcohol. The smart alecks in the crowd are now thinking, “Well I’ll just make sure to separate my antibiotic and alcohol by a long enough interval so that they’ll never meet in my stomach! I win!” We hope you can define a “long enough interval” (and if so, let us know) because everyone’s stomach empties these medications at different rates. As such, we can’t even being to make recommendations as to how much time you should allow for so that none of the antibiotic will meet the alcohol. The bottom line is that if you mix the above medications with alcohol, you’re asking for some serious punishment. You can’t say we didn’t warn you.
Medications: Loratadine, Fexofenadine, Diphenhydramine, Desloratadine, Loratadine, Brompheniramine, and Cetirizine
Having read Attack of the Common Cold, you know that antihistamines can help with a lot of cold symptoms. Since they’re available to buy at the pharmacy without a prescription, some people make the mistake of assuming they’re completely safe and won’t interact with other medications or alcohol. We are sorry to say that this assumption is wrong. On their own, antihistamines can cause some drowsiness. When mixed with alcohol, you might as well tuck yourself in for the night. Aside from making you drowsier, it’s also possible to become dizzy from a drop in your blood pressure. Dizziness can lead to falling and falling leads to all sorts of serious injuries (i.e. broken bones, concussions, etc.)(2). Antihistamines are found in all sorts of cough, cold, and allergy combination drugs like Nyquil so read the back of the label and see if any of the above medications are in there. We don’t recommend that you take antihistamines and drive until you know their affect on your level of alertness. If you’re going to drink and take antihistamines, absolutely do not drive (not that you need to be reminded that you should not drink and drive!).
Class: Cough Medications
Medication: Dextromethorphan (Robitussin)
If you’ve ever had a cough and taken Robitussin, you know how sedating it is. Imagine mixing alcohol with that. Two words: lights out. Mixing the two can lead to hallucinations and strange behavior (more so than alcohol alone). While this may sound like fun to some people, believe us when we tell you that it is dangerous and harmful to your brain (2). Don’t do it.
Class: Heartburn Medications
Medications: Nizatidine, Metoclopramide, Cimetidine, and Ranitidine
Heartburn is very unpleasant and we completely understand your need to alleviate that toxic feeling with medications. You pop a Zantac (Ranitidine) and start to feel better so you decide you will join your friends at the pub. What can you expect to happen after your second vodka tonic? Nothing good. Your heart rate will increase suddenly and so will your blood pressure. Imagine how the heartburn made you feel and amplify that ten-fold. In addition mixing alcohol with these medications can increase the affect alcohol has on you. If you’re someone who usually feels tipsy after six drinks you may start feeling not so great after two. This happens because the heartburn medications decrease the breakdown of alcohol in your stomach so your body is exposed to more alcohol than it normally would be. In turn, alcohol inhibits the metabolism of the heartburn medications so you experience more severe side affects from those medications (the increased heart rate and blood pressure) (2).
Class: Pain Relief
Medications: Ibuprofen, Naproxen, and Aspirin
Whatever the source of pain (cramps, muscle pain, hangover, headache, etc.) most people reach for one of these trusty painkillers. Aspirin has lost some of its popularity as a painkiller but Ibuprofen and Naproxen are gaining in popularity due to their anti-inflammatory properties that help with lots of different sources of pain. How do these trusty pain-alleviating friends of ours interact with alcohol? Ibuprofen, Naproxen, and Aspirin all disrupt the lining of your stomach and add to the erosive affects of alcohol. Combine the two and you asking for some serious stomach pain. Together they can completely disrupt the lining of your stomach and allow the acidic contents of your stomach to reach the stomach tissue. Long-term combination of alcohol and these agents can lead to bleeding in your stomach (a.k.a. gastrointestinal bleeding). Not fun and filled with long-term consequences. It’s generally recommended that you separate these agents and alcohol by 8-10 hours or play it safe and don’t combine them in the same day (1).
Class: Antipyretic (Anti-Fever)
Medication: Acetaminophen (Tylenol)
Tylenol can be used for both pain relief and to reduce fever. It gets its own separate section from the other pain relievers because it comes with an entirely different risk when combined with alcohol. Tylenol, like alcohol, is broken down by the liver. When Tylenol and alcohol meet in the liver, the alcohol causes Tylenol to be broken down into a toxic compound. This toxic compound causes the death of liver cells! Did your liver just quiver out of fear? We don’t blame it. Long-term combination of alcohol and Tylenol can cause liver failure, meaning that you’ll ultimately need a liver transplant. Not good. Avoid taking more than 4 grams of Tylenol a day and absolutely do not drink when taking Tylenol (1).
Medications: Phenelzine, Isocarboxazid, and Tranylcypromine
The antidepressants listed above are from the Monoamine Oxidase Inhibitor class (MAOI’s for short, we love acronyms in the medical world). They have lost popularity in recent years because of the many interactions they can have with food and alcohol. Aged foods (think salami, aged cheeses, etc.) and aged drinks (wine is the main culprit here) contain a compound called tyramine. The metabolism of tyramine is prevented when someone is taking MAOI’s so the tyramine builds up in your body. When tyramine builds up, it causes a sudden increase in heart rate and blood pressure that we call a hypertensive emergency (1). Yes, the kind of emergency people end up in the hospital for. So if you are taking any of these antidepressants, do not drink aged alcoholic beverages.
Medications: Diazepam, Lorazepam, Zolpidem, Eszopiclone, Estazolam, Ramelteon, Phenobarbital and Temazepam
The entire point of these medications is to help people fall asleep. Add on the sedating affects of alcohol and you’ll have an extremely un-alert person. This might not sound like reason enough not mix them with alcohol since being extra sleepy is something an insomniac may want. However, the downside is that you may become completely unaware of your actions and experience amnesia. On the other hand some people become aggressive and anxious due to combining these medications with alcohol (2). The reaction can vary from person to person. Even with the variance among individuals, all the manufacturers of these medications clearly warn against taking these medications with excessive amounts of alcohol.
Class: Opioid Pain Killers
Medications: Morphine, Oxymorphone, Meperidine, Methadone, Propoxyphene, Oxycodone, Hydromorphone, and Codeine
Generally prescribed for serious pain, the consequences of mixing these medications with alcohol are serious. Like with the sedatives, mixing these medications with alcohol can cause increased sedation, amnesia and loss of control. If that’s not enough to scare you then maybe the fact that you may stop breathing will. Opioid painkillers cause respiratory depression (decreased breathing) and alcohol adds to that affect (1). It is this combination of painkillers and alcohol that has claimed the lives of several celebrities in the past.
There are a lot of other medications that interact with alcohol but the medications above are the most commonly used in our society. Never assume it’s safe to combine medications or take medications with alcohol until you check with your pharmacist or doctor. One night of fun is not worth any long-term damage you may cause your self. The next time the answer is, “It’s probably best not to drink while on that medication,” trust us…we’re on your team. We’ll even take you out for a drink when you’re medication-free.
Questions? E-mail the Author: firstname.lastname@example.org
1. Alcohol Related Drug Interactions. Pharmacist’s Letter/Prescriber’s Letter. Jan 2008. Vol 24.
2. Harmful Interactions: Mixing Alcohol with Medicines. National Institute of Alcohol Abuse and Alcoholism. 2007.