TOPIC: CYP3A4 Inhibitors and Daclatasvir - Fruits

I have recently seen a patient get significant side effects from Daclatasvir due (we suspect) to his daily Paw Paw habit. These disappeared with a small dose reduction, but reappeared with increasing the dose.

At 68 kg weight was not the issue, but a careful history revealed he eats Paw Paw every day, and Dr Google came to the rescue turning up this new page:

www.ganfyd.org/index.php?title=Inhibitors_of_CYP3A4

So while Grapefruit juice is known to be a problem Paw Paw, Star Fruit and Pomegranate are also fruits to avoided.

Edit: Grapes have also been observed to cause issues, so add them to the list.

Damn, pawpaws have been really yummy this season. I quit them shortly after starting tx after seeing the same linked article in another thread.
I hope lychees are ok, they're good now too. In moderation, they have decent amount of Vitamin C which is also contraindicated.

It would be great to have a sticky for common foods, vitamins and herbals to avoid during treatment, and recommend any that are helpful. IIRC, gingko, ginseng and St Johns Wort have been mentioned. Drug interactions can already be searched.

I'm glad I read this. I was going to get a big old paw paw out of the fridge and add it to my juice tomorrow. Thank you.

Thank you so much for taking the time to check this problem out for me, James. It's been just over a week now without any paw paw and my sides continue to be no where near as bad as what they were. It's a shame it took 5 months of suffering to find out that eating this fruit was probably the cause of all my problems; having the Daclatasvir build up in my system. At least I should now be able to cruise through the final few weeks of tx in peace.

Big thanks also to Sylvia Price for all her wonderful info she passed on and also for contacting you to raise this issue.

Great people! Great forum!

Thats what you get for being so healthy BillyM

If you think about it the clue was provided by your brief trial of dose reduction and the sides improving.

Then when we took into account your average weight, and lack of medications that could be doing it we got into supplements, and then diet.

So really you not only helped cure yourself, you have probably saved a number of other people from having similar problems.

There is a real power in crowd sourced knowledge.

Ha! Maybe I should have just stuck with toast for breakfast and steak and 3 veg for dinner!

No marmalade on the toast though, just in case it had Seville oranges or grapefruit it it!

Sorry to further dampen things BillyM - red meat (saturated fats) is very hard work for the liver to process; you eat that and probably feel very bloated and tired and need a Siesta to get through it

How about fish and brown rice with steamed carrots, broccolini, baby corn, snow peas, with a spoonful of coconut milk and lime juice ..mmmmm

Brown rice is far better for you than white - brown only has outer hull removed and hence saves most of the nutrients, white is stripped down so badly it actually has to be fortified with vitamins to be sold here.
Brown rice has protein, fibre, very minimal fat and no other sugars than tiny amount of sucrose; all the Vitamin B complex, minerals - magnesium, manganese, selenium, phosphorus, copper, zinc, iron, calcium, chromium; and NO vitamin A, C, D, E!
Fish will give you protein and omega 3 (depending on type e.g. Salmon is higher), easy to digest; carrots - betacarotene -converts to Vitamin A in your body; broccolini - protein (surprised?) fibre, calcium, potassium, betacarotene, B6 and folate, Vitamin C and other trace minerals.
Awesome, I feel hungry just talking about it


Nevertheless, the fact is we no longer can get the Recommended Daily Allowance of our nutrients from food as our grandparents did. Our soils are depleted by overfarming and pesticides; our produce is stored for weeks and months in refrigeration before it reaches our shelves; buying things cut up rather than whole depletes nutrients through oxidation (exposure to air) and the way we cook can further reduce things. Sickness, stress and poor diet/appetite further depletes our bodies and makes us deficient and more time indoors means lack of sunshine and vitamin D. Living in the UK - apparently widespread deficiency of Vitamin D.

Everything works synergistically so taking some supplements without others can be a waste of time because they can't be assimilated in the body. It really is hard to work out what's best for us individually .....

Now, the following is just anecdotal with no science behind it, probably as much about moderation as CYP3a4 inhibitors:

About 3-4 weeks ago my sides seem to be increasing somewhat, nothing real bad but I just wasn't feeling that great any more, nothing I could really put a finger on, just a little bleah! Then 2 weeks ago I was reading one of Greg's posts on his blog and he included Grapes in the list of items that were potential CYP3a4 inhibitors that should be avoided when on Daclatasvir. My first thought was "nup, grape seed oil is an inhibitor but not grapes". A very quick google confirmed that I was correct so I grabbed another handful of grapes out of the fruit bowl. Hey, it's grape season and they're $3-4 a kilo and I like grapes so there is always a bunch in the bowl and I graze as I walk past throughout the day, probably 5-6 times a day, at least 1/4 to 1/3 kg a day!!! Ohh.....wait! Maybe time for some more research? Well I still couldn't find anything specific but grape seeds used to make the oil come from grapes and grape skins contain resveratrol which has some effects as a 3a4 inactivator www.ncbi.nlm.nih.gov/pubmed/11125847.

Anyway, nothing definite but I decided that this year I could probably live without gorging myself on grapes. The slightly toxic effects I was feeling seem to have gone now too. Maybe it was related, maybe it wasn't? Maybe I was just eating too many grapes? I don't know but thought I would include here just in case others were eating a lot of grapes and had sides.

And on the moderation thing, I suggest you do as I say rather than follow what I do!

Similarly early in treatment I was eating way too many raspberries-big season just going on and on- I was also on riba at the raspberry stage but I felt so ill, I blamed it all on the meds. But I had the impression at the time, I wasn't just flushing red in face but an unnatural sort of purple! A relative just sent me a photo and it is clear- I was turning into a raspberry right when I was weakest. I suppose the moral would be nothing in excess, but I'm tempted to say add raspberries to the fruits to reduce or avoid.

I'm pretty sure I posted it here but there was a vegetarian lady with a fairly large daily grape consumption getting daclatasvir side effects.

A dose reduction showed instant effect, and a grape reduction seems to have solved the issue.

So the list of no go fruits is grapefruit, grapes, pawpaw, starfruit and pomegranate

There are almost certainly other things that will cause issues.

To me the best solution is to eat a bit of everything and not too much of anything.

Looks like I can't even RTFM, now I'm even more embarrassed!

Hi Gaj,

Actually it's my fault. I knew about it and mentioned it under Taurine (as you do!)

fixhepc.com/forum/experts-corner/714-tau...t-failure.html#10953

....but did not add it to the fruit list. My bad.

Interesting to see that it has been independently observed!

So although Oscar Wilde is quoted

“Everything in moderation, including moderation.”

with food and DAAs I think variety and moderation are good ideas.

RecSofo/DAC - It seems some things induce and some things inhibit?
*Confused*