Quinine Sulfate interactions

Food & lifestyle

• food

  Minor

  Others

  Coadministration with grapefruit juice does not appear to affect the pharmacokinetics of quinine in a clinically relevant manner. Although grapefruit juice is an inhibitor of CYP450 3A4 and quinine is metabolized by this pathway to its major metabolite, 3-hydroxyquinine, a study of ten healthy volunteers found no significant differences in quinine peak plasma concentration (Cmax), time to reach Cmax (Tmax), terminal elimination half-life, systemic exposure (AUC), or apparent oral clearance (Cl/F) when a single 600 mg oral dose of quinine sulfate was administered in combination with 200 mL of orange juice (control), half-strength grapefruit juice, and full-strength grapefruit juice twice daily for 6 days each, separated by a 2-week washout period. Relative to the control period, the apparent renal clearance of quinine was markedly increased by 81% during treatment with half-strength grapefruit juice. However, since renal clearance accounts for approximately 6% of the total clearance of quinine, this change would likely have minimal clinical impact. The lack of a significant interaction is probably due to the fact that grapefruit juice primarily inhibits intestinal rather than hepatic CYP450 3A4, and quinine is not known to undergo significant presystemic metabolism as evidenced by its relatively high oral bioavailability (76% to 88%). Nevertheless, excessive consumption of grapefruit juice and tonic water (which contains quinine) was suspected as the cause of torsade de pointes arrhythmia in a patient with a history of asymptomatic long QT syndrome. Treatment with magnesium sulfate and metoprolol had no effect, but the arrhythmia resolved spontaneously 48 hours after discontinuation of the drinks.

  What to do: Based on current data, moderate grapefruit juice consumption is probably safe for the majority of patients taking quinine.

  5 sources

  1. Ho PC, Chalcroft SC, Coville PF, Wanwimolruk S "Grapefruit juice has no effect on quinine pharmacokinetics." Eur J Clin Pharmacol 55 (1999): 393-8
  2. Hermans K, Stockman D, Van den Branden F "Grapefruit and tonic: a deadly combination in a patient with the long QT syndrome." Am J Med 114 (2003): 511-2
  3. "Product Information. Qualaquin (quinine)." AR Scientific Inc (2006):
  4. Zhang H, Coville PF, Walker RJ, Miners JO, Birkett DJ, Wanwimolruk S "Evidence for involvement of human CYP3A in the 3-hydroxylation of quinine." Br J Clin Pharmacol 43 (1997): 245-52
  5. Mirghani RA, Yasar U, Zheng T, et al. "Enzyme kinetics for the formation of 3-hydroxyquinine and three new metabolites of quinine in vitro; 3-hydroxylation by CYP3A4 is indeed the major metabolic pathway." Drug Metab Dispos 30 (2002): 1368-71

Conditions

Conditions in which Quinine Sulfate needs care, as documented in this source.

• Glucosephosphate Dehydrogenase Deficiency

  Major

  The use of quinine is contraindicated in patients with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency. Red blood cells are more easily destroyed in patients with G-6-PD deficiency and may lead to hemolysis and anemia.

  2 sources

  1. Tafani O, Mazzoli M, Landini G, Alterini B "Fatal acute immune haemolytic anaemia caused by nalidixic acid." Br Med J 285 (1982): 936-7
  2. "Product Information. QuiNINE Sulfate (quiNINE)." Zenith Goldline Pharmaceuticals

• Long QT Syndrome

  Major

  The use of certain antimalarial agents is contraindicated in patients with known prolongation of QT interval as these patients can develop fatal arrhythmias. These drugs should also be avoided in patients with clinical conditions known to prolong the QT interval, such as uncorrected hypokalemia or hypomagnesemia, bradycardia, and certain other cardiac conditions. Caution is advised in patients taking other medications that can prolong the QT interval.

  3 sources

  1. "Product Information. QuiNINE Sulfate (quiNINE)." Zenith Goldline Pharmaceuticals
  2. "Product Information. Qualaquin (quinine)." AR Scientific Inc (2006):
  3. "Product Information. Coartem (artemether-lumefantrine)." Novartis Pharmaceuticals (2009):

• Myasthenia Gravis

  Major

  The use of quinine is contraindicated in patients with myasthenia gravis, as quinine has neuromuscular blocking activity, and may exacerbate muscle weakness.

  1 source

  1. "Product Information. Qualaquin (quinine)." AR Scientific Inc (2006):

• Thrombocytopenia

  Major

  Quinine is contraindicated in patients with thrombocytopenia. Quinine can produce an immune-mediated thrombocytopenia. Severe cases of thrombocytopenia that are fatal or life threatening have been reported. Chronic renal impairment associated with the development of TTP has also been reported. Thrombocytopenia usually resolves within a week upon discontinuation of quinine. If quinine is not stopped, patients can be at risk for fatal hemorrhage. Upon re- exposure to quinine from any source, a patient with quinine- dependent antibodies could develop thrombocytopenia that is more rapid in onset and more severe than the original episode.

  1 source

  1. "Product Information. QuiNINE Sulfate (quiNINE)." Zenith Goldline Pharmaceuticals

• Tinnitus

  Major

  The use of quinine is contraindicated in patients with tinnitus. Quinine has been associated with reversible and irreversible ototoxicity. Reversible hearing loss, tinnitus, and dizziness has been reported in 20% of patients receiving therapeutic doses of quinine. Cystic degeneration of stria vascularis, degeneration of the cochlear neurons, and loss of hair cells occur. Injury may be produced by spasm of cochlear blood vessels, resulting in anoxia and subsequent cellular damage.

  1 source

  1. "Product Information. QuiNINE Sulfate (quiNINE)." Zenith Goldline Pharmaceuticals

• Toxic Optic Neuropathy

  Major

  The use of quinine is contraindicated in patients with optic neuritis, and cautious use, if at all, is advised for patients with retinopathy or other visual defects. Quinine may affect the retina and optic nerve, producing visual disturbances that include blurred vision with scotomata, photophobia, diplopia, constricted visual fields, night blindness, and abnormal color perception. Although ocular toxicity is usually reversible following drug withdrawal, retinopathy and optic atrophy can occur in severe cases. All patients should be advised to immediately discontinue the drug and contact a physician if visual disturbances occur or are exacerbated during quinine therapy.

  1 source

  1. "Product Information. QuiNINE Sulfate (quiNINE)." Zenith Goldline Pharmaceuticals

• Kidney Diseases

  Moderate

  Clearance of quinine is decreased in patients with severe chronic renal failure. The dosage and dosing frequency should be reduced. The effects of mild and moderate renal impairment on the safety and pharmacokinetics of quinine sulfate are not known. Monitoring is advised.

  1 source

  1. "Product Information. Qualaquin (quinine)." AR Scientific Inc (2006):

• Liver Failure

  Moderate

  In patients with severe hepatic impairment (Child-Pugh C), quinine oral clearance is decreased, volume of distribution is increased, and half-life is prolonged, relative to subjects with normal liver function. Therefore, quinine is not indicated in patients with severe hepatic impairment and alternate therapy should be administered. Adjustment of the recommended dose is not required in mild (Child-Pugh A) or moderate (Child-Pugh B) hepatic impairment, but patients should be monitored closely for adverse effects of quinine.

  1 source

  1. "Product Information. Qualaquin (quinine)." AR Scientific Inc (2006):

Therapeutic duplication

Drug classes that overlap with Quinine Sulfate, so taking both doubles up the same effect. This source publishes no per-row citations for duplication.

• antimalarials

  The recommended maximum number of medicines in the 'antimalarials' category to be taken concurrently is usually one.Your list includes two medicines belonging to the 'antimalarials' category.

  Example product in the source data (US market): Coartem