← Medication interactions guide · A · B–C · D–L · M–O · P–S · T–Z
General information for discussion with your doctor, pharmacist or vet. It is not medical or veterinary advice. Never stop or change a medication without talking to your prescriber.
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T
Tacrolimus
Trade names Advagraf, Protopic, Prograf
An immunosuppressant used after organ or bone marrow transplants, but also used for topical conditions such as vitiligo, eczema, psoriasis and lichen sclerosis. It’s prescribed in eye drops in veterinary use for dogs and cats. It inhibits the production of calceneurin, which then reduces the production of IL-2, and thence the production of T cells. Prescriber information mentions the consumption of grapefruit juice as a precaution (because of its mechanism as a CYP3A4 inhibitor). Golden Paste would thus be a caution as well. Tacrolimus is cleared primarily via CYP3A4, and its side effects are wide-ranging and potentially severe so overdosage carries serious risk.
At least one known case of nephrotoxicity occured in a man who added ‘high dose turmeric’ along with tacrolimus. This was almost certainly a curcumin extract and not just a large amount of turmeric. But curcumin is itself a CYP3A4 inhibitor. It is probably a more potent inhibitor than the pepper in Golden Paste, but there would still be an elevated level of risk with the Golden Paste. Doctor or vet consult required.
More detail and references
References:
Drugbank: https://www.drugbank.ca/drugs/DB00864Acute Calcineurin Inhibitor Nephrotoxicity Secondary to Turmeric Intake: A Case Report
https://pubmed.ncbi.nlm.nih.gov/28104136/
Tamsulosin
Trade names Flomax, Alna, others
An alpha blocker used primarily to treat benign prostatic hyperplasia and urinary retention. It’s main metabolic pathway is via CYP3A4, so physician consult is recommended before adding Golden Paste.
NOTE: We have had at least one report of problems even after the person’s physician told them it was okay – the man experienced a constant need to urinate small amounts which stopped when he stopped the Golden Paste, and recurred when he restarted it.
Tantum Verde: see Benzydamine
Tapentadol
The new and improved version of tramadol, which is arguably not hard to do.
So, how is the new kid on the block different? Tapentadol is not a prodrug – it does not rely on metabolism to get it working. So it is what it says on the box – an opioid analgesic. In addition:
- it has a strong mu-opioid receptor agonist effect, similar to oxycodone
- it has noradrenaline reuptake inhibitory effects, but not much effect on serotonin reuptake, which makes it a little cleaner
- there are no active metabolites yet known – so that sounds cleaner, too.
- Metabolized via glucuronidation (97%)
- ok with turmeric and most likely also with Golden Paste and the Dog Bites
Taxol: see Paclitaxel
Taxotere: see Docetaxel
Tegretol: see Carbamazepine
Telmisartan
Trade name Semintra and others
Antiotensin II receptor blocker (ARB) for blood pressure, may also be prescribed for kidney failure to reduce kidney blood pressure. Generally okay with Golden Paste or curcumin. Semintra is a veterinary trade name.
Temaril-P
Combination phenothiazine antihistamine & corticosteroid used for pruritus & potentially as an antitussive. Probably ok with turmeric. Temaril is not for long term use.
- Relatively contraindicated: Systemic fungal infections, hypovolemia, or shock & in patients with tetanus or strychnine intoxication. Caution: Hepatic dysfunction, cardiac disease, active bacterial or viral infections, peptic ulcer, acute psychoses, corneal ulcer, hypercortisolism (Cushing’s syndrome), diabetes, osteoporosis, chronic psychotic reactions, predisposition to thrombophlebitis, hypertension, CHF, renal insufficiency, general debilitation, very young animals.
- Primary adverse effects: Sedation, significant hypotension, cardiac rate abnormalities, hypo- or hyperthermia, Cushing’s effects with sustained use.
- Many potential drug & lab interactions.
Terazosin
Trade names Hytrin and others
An alpha-1 blocker prescribed primarily to treat prostate enlargement. It will also reduce blood pressure. it is not typically prescribed by itself for hypertension, as it is a less effective firstline treatment for hypertension that many others. It may be prescribed when hypertension is accompanied by prostate enlargement. On its own, it’s unlikely to be a problem with Golden Paste, but in combination with multiple other hypertension medications, given that turmeric has a similar mechanism, physician consent should be recommended.
Terbinafine
Trade names Lamisil, others
An antifungal available both orally and more common, as a cream or an ingredient in an antifungal cream. It’s a substrate of both CYP3A4 and CYP2C9 (which curcumin inhibits), but trials suggest that the interaction is minor and not significant in most cases. Probably okay with Golden Paste, especially in topical form.
Tergive: see Carprofen
Terramycin: see Oxytetracycline
Teva-Furosemide: see Furosemide
Thalidomide
Trade name Thalomid
Prescribed for multiple myeloma, graft-versus-host disease, and a number of skin conditions including complications of leprosy. It’s metabolized in part by both prostaglandin 1 and 2 (COX-1 and COX-2). Since turmeric is a COX-2 inhibitor (with some effect on COX-1 as well), its clearance could be affected by the use of Golden Paste. Physician or vet checked recommended.
Tizanidine
Trade names Relentus, Sirdalud, Zanaflex
A potent muscle relaxer, primarily metabolized via CYP1A2, shouldn’t be a problem with Golden Paste, especially as it is typically used only as needed. Should not be used along with the fluroquinolone antibiotics, as this can result in a much higher plasma concentration.
Tobramycin
Trade names Tobrex, Tobradex, Nebcin, Tobi
An antibiotic that is not absorbed from the gastrointestinal system. It must be given via IV or IM. It is also available as an opthalmic solution (Tobrex), an opthalmic solution combined with dexamethasone (Tobradex) and as a nebulized product (Tobi). The injectable form is sold under the brand name Nebcin. It should be okay with Golden Paste.
Toceranib
Trade name Palladia
A tyrosine kinase inhibitor (as is turmeric). Palladia is cleared via CYP3A4, which could mean higher serum levels than expected if Golden Paste is fed along with it. However, we’ve had no reports of adverse events in the dogs who have had Golden Paste along with Palladia. Its prescriber information does caution about its use with potent CYP3A4 inhibitors, which would include both curcumin and CBD. To be on the safe side, we would recommend vet consultation.
Tolfenamic Acid
Trade name Tolfedine
Tolfenamic acid exhibits pharmacologic actions similar to those of aspirin. It is a potent inhibitor of cyclooxygenase, thereby inhibiting the release of prostaglandins. It also has direct inhibition of prostaglandin receptors. Tolfenamic acid has significant antithromboxane activity and is not recommended for use presurgically because of its effects on platelet function. It is my preferred drug to treat Ephemeral Fever in cattle but for other inflammatory issues there are better drugs. It is a NSAID and compatible with turmeric. Together the anticoagulant effect will be greater.
Tolterodine Tartrate
Trade names Detrol, Detrusitol
Prescribed for over-active bladder. It’s a muscarinic receptor antagonist, which means typical amounts of turmeric will act in opposition to it. It’s also cleared via CYP3A4. Physician consult required.
Topiramate
Trade name Topamax
An anti-convulsant, which is also available in the US in combination with phentermine as a weight-loss drug. It has been prescribed off-label for a very wide variety of conditions, from borderline personality disorder to bipolar disorder to cluster headaches. It’s cleared via CYP3A4. There is another drug called Toprol-XL, which is completely different (it’s an extended release version of metoprolol), so if there is any possibility of confusion between the two, make sure the member has confirmed which one it is.
Topotecan
Trade name Hycamtin
Cancer medication used for ovarian cancer and small-cell lung cancer, and sometimes for cervical cancer, Ewing’s sarcoma or other soft-tissue sarcomas. The manufacturer says specifically that curcumin inhibits topotecan-induced apoptosis and to avoid concomitant use.
Toprol-XL: see Metoprolol
Tramadol
Trade names Tramal and others
An opioid pain medication and also a serotonin-norepinephrine reuptake inhibitor. Going by textbook interactions, this should be a problem with Golden Paste, but experience in the group has not indicated anything significant with dogs, for whom it is most frequently prescribed. We have had one report of an adverse interaction in a human, but were unable to follow up on it (she didn’t respond to questions).
Tramadol is possibly one of the most maligned medications in a Golden Paste’s toolbox.
It’s an opioid used for pain management. But it’s unpredictable, with a lot of side effects, and often just doesn’t provide much relief. It’s an older drug, dating back to 1977.
Tramadol is a prodrug. That means, on its own it doesn’t do much of anything. It gets metabolised in the liver by the cytochrome p450 enzymes into a few active chemicals.
More detail and references
But here is the problem – the actual amounts of each of the active metabolites is a bit of a genetic lottery. Depending on the makeup of your cytochromes, you may get:
- a bunch of destramadol (aka M1), which has a strong mu-opioid receptor affinity and acts like morphine
- some venlafaxine, which is a serotonin/noradrenaline reuptake inhibitor (SNRI)
- a mixture of both of the above
- a whole bunch of other receptors, such as N and M acetylcholine, direct serotonin agonists, and the list goes on.
To some extent, you can ask a patient what effects they felt if they had a dose of tramadol previously.
you get pretty clear likes or aversion to tramadol. The most common reply is along the lines of, ‘Oh, the drug that made me spew’.
Then there is the risk of serotonin syndrome and seizures. This may come about for a few reasons:
- Older patients or people with renal/liver disease don’t clear metabolites and they build up
- Combining it with other serotonin norad-active drugs like antidepressants leads to a double whammy
- Patients with little metabolism to M1 take more and more doses to achieve analgesia and end up with a bunch of the SNRI metabolites in their systems
All in all, a tricky drug to use, since different patients may have a totally different experience with the drug.
Tramal: see Tramadol
Trazodone
Trade names Desyrel, Molipaxin, Oleptro, Trazorel, Trittico
An anti-depressant of the serotonin-antagonist reuptake inhibitor (SARI) class. It is metabolized primarily via CYP3A4 and glucuronidation. The potential therefore exists for Golden Paste to slow its clearance both via pepper’s inhibition of the metabolic pathways and the action of both turmeric and pepper as non-selective MAO inhibitors. But it has only weak SSRI action and has not, in real life use, been a problem along with Golden Paste in veterinary use. Even so, the potential exists for over-sedation, and interaction cautions should include consulting with one’s vet if a dog appears to react adversely.
In human use, side effects have included cardiac arrhythmia, orthostatic hypotension, prolonged QT intervals and rarely, priapism or liver toxicity. These are not the only side effects, however, so reports of unexpected reactions to adding Golden Paste should be taken seriously.
Trelegy
Trelegy Ellipta. See also Anoro, Breo and Incruse
The Ellipta inhalers use two or three medication strips as opposed to the Diskus inhalers and others that use only one. Trelegy includes three – fluticasone, umeclidium and vilanterol. There don’t appear to be any significant interactions with Golden Paste with the Trelegy product. It’s prescribed for COPD and asthma.
Triamterene
Trade name Dyrenium, and others
Triamterene is a potassium-sparing diuretic (often prescribed along with hydrochlorothiazide under the trade name Maxzide). It’s metabolized primarily via CYP1A2, so it’s unlikely to have metabolic interactions with Golden Paste, though it could be a problem along with curcumin (which inhibits CYP1A2). The primary problem with a curcumin extract, though, is that it is also a potassium-channel blocker, so the combination of curcumin and triamterene could result in excessive serum levels of potassium. Elevated levels of potassium have not been a problem with Golden Paste, and I wouldn’t expect to see it along with triamterene either.
Tricor: see Fenofibrate
Trofurit: see Furosemide
Trusopt: see Dorzolamide
U
UDCA: see Ursodeoxycholic acid
Udcasid, Udiliv, Udoxyl, Udimarin: see Ursodeoxycholic acid
Ultram: see Tramadol
Uremide: see Furosemide
Urex: see Furosemide
Urso, Ursocol, Ursofalk, Ursosan, Urseserinox, Ursonova: see Ursodeoxycholic acid
Ursodeoxycholic Acid, Ursodiol
Trade names Destilit, Actigall, Biliver, Coric, Deursil, Egyurso, Udcasid, Udiliv, Udoxyl, Urso, Urso Forte, Ursocol, Ursofalk, Ursosan, Ursoserinox, Udimarin, Ursonova, and Stenerh, possibly others
Prescribed for high cholesterol, works by inhibiting the rate at which the intestine is able to absorb cholesterol. Because of that, it may also inhibit the absorption of turmeric. It is also used for the non-surgical treatment of cholesterol gallstones.
Appears to be okay with Golden Paste.
Uses / Indications
In small animals Ursodeoxycholic acid may be useful as adjunctive therapy for the medical management of gallbladder mucocele and sludge accumulation; it may also be used in patients with chronic liver disease, particularly cases in which cholestasis (ie, bile toxicity) plays an important role. It can be used as part of the medical treatment of gallbladder mucoceles; however, surgical correction is indicated in many patients, and surgery is specifically indicated when bile peritonitis is present. Medical management can be considered in cases with early development of the mucocele that is nonobstructive. Ursodiol will not dissolve calcified radiopaque stones or radiolucent bile pigment stones in small animals. Ursodiol’s benefit in treating canine or feline hepatobiliary disease is not known, but it may be helpful in slowing the progression of inflammatory hepatic disorders, particularly autoimmune hepatitis and acute hepatotoxicity.
More detail and references
In humans, ursodiol is used for dissolution of small (less than 2 cm), radiolucent, noncalcified gallstones in patients who are not candidates for surgery. It may also be used to prevent gallstone formation and for the treatment of primary biliary cirrhosis.
Pharmacology / Actions
After oral administration, ursodiol suppresses hepatic synthesis and secretion of cholesterol. Ursodiol also decreases intestinal absorption of cholesterol. By reducing cholesterol saturation in the bile, it is thought that ursodiol allows solubilization of cholesterol-containing gallstones. Ursodiol also increases bile flow and, in patients with chronic liver disease, apparently reduces the hepatocyte toxic effects of bile salts by decreasing their detergent action and may protect hepatic and bile duct epithelial cells from toxic bile acids (eg, lithocholate, deoxycholate, chenodeoxycholate). In patients with chronic hepatitis, ursodiol may also reduce hepatocellular inflammatory changes and fibrosis. It does not have GI prokinetic effects.
Pharmacokinetics
Ursodiol is well absorbed from the small intestine after oral administration. In humans, up to 90% of dose is absorbed. After absorption, it enters the portal circulation. In the liver, it is extracted and conjugated with either taurine or glycine and secreted into the bile. Ursodiol concentrates in the gallbladder, and concentration in bile plateaus at ≈30% to 50% of total bile acid after ≈3 weeks. It is secreted into the duodenum, where intestinal or bacterial enzymes may deconjugate it, allowing it to be absorbed, enters the portal circulation, and is then reconjugated in the liver. After each enterohepatic cycle, some quantity of conjugated and free drug undergoes bacterial degradation; eventually, most of the drug is eliminated in the feces as unchanged ursodiol or after being oxidized or reduced to less soluble compounds, including lithocholic acid. The very small quantities of ursodiol that enter the systemic circulation are highly (70%) bound to plasma proteins, and <1% is excreted in urine.
Contraindications / Precautions / Warnings
Ursodiol is contraindicated in rabbits and other hindgut fermenters, as it is converted into lithocholic acid, which is hepatotoxic. The drug is also contraindicated in patients hypersensitive to it or other bile acid products and in patients with complete biliary obstruction. The benefits of using ursodiol should be weighed against its risks in patients with complications associated with gallstones (eg, biliary obstruction, biliary fistulas, cholecystitis, pancreatitis, cholangitis). Some state that ursodiol should not be used unless bile duct obstruction has been ruled out; although it is not a substitute for surgery, others state that because ursodiol does not have biliary prokinetic effects, it is not contraindicated. Ursodiol does not dissolve radiopaque stones, calcified cholesterol stones, or radiolucent bile pigment stones.
Patients with chronic liver disease may experience further impairment of bile acid metabolism.
Adverse Effects
Ursodiol use in animals has been limited, but it appears to be well tolerated in dogs and cats. Although hepatotoxicity has not been associated with ursodiol therapy in humans, there are some human patients with an inability to sulfate lithocholic acid (a naturally occurring bile acid and also a metabolite of ursodiol). Lithocholic acid is a known hepatotoxin; clinical significance in dogs and cats is unclear. Elevated liver enzymes, diarrhea, abdominal pain, and other GI effects have rarely been noted in humans taking ursodiol. A study in healthy dogs showed no changes in liver enzymes, bilirubin, cholesterol, or triglyceride concentrations after 6 to 8 weeks of ursodiol administration.1
Ustekinumab
Trade name Stelara
A human immunoglobulin (Ig) G1 kappa monoclonal antibody prescribed primarily for plaque psoriasis, but also for Crohn’s. It is an IL-12 and IL-23 inhibitor and also a TNF-α inhibitor. Its metabolism has not been well characterized, but it does not appear to involve cytochrome P450 enzymes or P-gP. Protein binding also not well characterized but does not appear to be significant. The curcumin in turmeric has been shown to be a dose-dependent inhibitor of the same cytokines as ustekinumab, and the two should go well together.
A study is currently under way to evaluate the effect of ustekinumab on cytochrome P450 activity, but is not expected to complete until 2022. At this writing (July 2020), no data has been released.
More detail and references
Elimination half life: 15–32 days (average 3 weeks)
Drugbank: https://www.drugbank.ca/drugs/DB05679
FDA prescriber information: https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/761044lbl.pdf
V
Valeant: see Colesevelam
Valium: see Diazepam
Valproic Acid: see Sodium valproate
Vasotec: see Enalapril
Venlafaxine
Also known as: Effexor
Mechanism of Action:”Bicyclic” antidepressant; drug is structurally unrelated to SSRIs, MAOIs, and tricyclic antidepressants (TCAs), but it and its metabolite are potent inhibitors of serotonin and norepinephrine reuptake and weak inhibitors of dopamine reuptake; it does not have MAOI activity or activity for H1 histaminergic, muscarinic cholinergic, or alpha2-adrenergic receptors
Hypersensitivity Coadministration with serotonergic drugs: Coadministration with monoamine oxidase inhibitors (MAOIs) Concomitant MAOIs administration within 14 days before initiating venlafaxine or within 7 days after discontinuing venlafaxine. Initiation of venlafaxine in patients being treated with linezolid or IV methylene blue.
More detail and references
Metabolized in liver by CYP2D6
Caution with turmeric which also increases serotonin.
Effexor also has a reputation for unpredictable reactions in human patients, mostly manic behavior.
Verapamil
A calcium-channel blocker for high blood pressure. It is also, like black pepper, a P-glycoprotein inhibitor. This isn’t directly relative to the use of Golden Paste along with it (which is okay). But it may be something to keep in mind if someone is taking other medications metabolized by P-gP, since there could be additive effects from the verapamil and Golden Paste.
Vesicare: see Solifenacin succinate
Vetmedin: see Pimobendan
Vetprofen: see Carprofen
Viagra: see Sildenafil
Vicodin: see Codeine
Vinblastine
Also known as: Velban
Not compatible
When cells were pretreated with curcumin, microtubule filaments were disordered. Vinblastine-induced microtubule depolymerization and cell death were reduced in HeLa human cervical cancer cells pretreated with curcumin compared to the control. The decrease in cell death was much greater in cells pretreated with curcumin compared to co-treatment or post-treatment. DNA condensation by vinblastine was also decreased in curcumin-pretreated cells. Curcumin reduced ROS production by vinblastine. However, no changes in vinblastine-mediated microtubule depolymerization were detected upon N-acetylcysteine(NAC) treatment. In contrast, vinblastine-induced MMP collapse was inhibited by pretreatment with curcumin or NAC. These findings suggest that vinblastine-induced tumor cell death might be inhibited by curcumin via ROS-independent microtubule dynamics and ROS-dependent MMP collapse. It also suggests that microtubule dynamics could be necessary for the optimal antitumor activity of vinblastine. Our results suggest that patients treated with vinblastine should not consume curcumin.
Vivitonin
Also known as: see propentofylline
Vortioxetinum (Brintellix)
Vortioxetine’s mechanism of action is not fully understood. Vortioxetine binds with high affinity to the serotonin transporter and its antidepressant actions are believed to be secondary to enhancing serotonin in the central nervous system through inhibition of reuptake. Vortioxetine also displays binding affinities to other serotonin (5-HT) receptors, including 5-HT3, 5-HT1A, and 5-HT7, with Ki values of 3.7 nM, 15 nM, and 19 nM, respectively.
There is moderate affinity toward serotonin receptors 5-HT1D and 5-HT1B, with Ki values of 54 nM and 33 nM, respectively.
Vortioxetine’s binding affinity is dose-proportional: Raising the dose will cause more binding to the receptors of interest at an increase of 15% for every 5 mg up to the maximum dosage.
More detail and references
Based on the receptor binding affinities, vortioxetine displays reuptake blockade of the serotonin transporter, agonist activity at the 5-HT1A receptor, partial agonist activity at the 5-HT1B receptor, and antagonism at the 5-HT1D, 5-HT7, and 5-HT3 receptors.
It has not been determined whether the antidepressant effects of vortioxetine are related to its binding at various 5-HT receptors.
Since vortioxetine is an agonist and antagonist of multiple serotonin receptors, potential interactions may occur with other medications that alter the serotonergic pathways. There is an increased risk of serotonin syndrome when vortioxetine is used in combination with other serotonergic agents. Medications that should be avoided because of the increased risk of serotonin syndrome when combined with vortioxetine include SNRIs, SSRIs, TCAs, triptans, MAOIs, linezolid, methylene blue, meperidine, fentanyl, pentazocine, lithium, tramadol, and antipsychotic agents. St. John’s wort and dextromethorphan, common over-the-counter medications, should also be avoided because of their serotonergic effects. 10 Vortioxetine has been known to cause abnormal bleeding, so drugs that affect hemostasis should be used with caution. These drugs include nonsteroidal anti-inflammatory drugs, warfarin, and aspirin. Patients should watch for signs and symptoms of abnormal bleeding.
10. Vortioxetine has many metabolizing pathways, including cytochrome P450 isozymes CYP2D6, CYP3A4/5, CYP2C19, CYP2C9, CYP2A6, CYP2C8, and CYP2B6; the main enzyme is CYP2D6. Drug interactions involve inhibitors and inducers of CYP2D6. The dose of vortioxetine should be reduced by half when it is combined with strong CYP2D6 inhibitors, and the dose of vortioxetine should be increased if strong CYP2D6 inducers are used for 14 days or longer (up to three times the maximum recommended dose can be used with strong CYP2D6 inducers)
W
Welchol: see Colesevelam
Wellbutrin: see Bupropion
Winbp: see Olmesartan
X
Xanax: see Alprazolam
Xarelto
Also known as: rivaroxaban
We don’t have detailed notes on this medication yet. Ask Dr Doug if you need to know.
Xeloda: see Capecitabine
Z
Zanaflex: see Tizanidine
Zelcor: see Carprofen
Zemtard: see Diltiazem
Zeniquin: see Marbofloxacin
Zohydro ER: see Codeine
Zolendronic Acid
Trade names Aclasta, Reclast, Zometa
A bisphosphonate drug given by IV to reduce the bone loss caused by some cancer meds and some illnesses (Paget’s Disease and others). Should be okay with Golden Paste.
Zoloft: see Sertraline
Zometa: see Zolendronic acid
Zyban: see Bupropion
Can’t find your medication? Ask Dr Doug and it may be added to the guide. A · B–C · D–L · M–O · P–S · T–Z
