1.

chlorpheniramine dengan makanan (Moderate)

GENERALLY AVOID: Alcohol may potentiate some of the pharmacologic effects of
CNS-active agents. Use in combination may result in additive central nervous
system depression and/or impairment of judgment, thinking, and psychomotor skills.
MANAGEMENT: Patients receiving CNS-active agents should be warned of this
interaction and advised to avoid or limit consumption of alcohol. Ambulatory patients
should be counseled to avoid hazardous activities requiring complete mental
alertness and motor coordination until they know how these agents affect them, and
to notify their physician if they experience excessive or prolonged CNS effects that
interfere with their normal activities
2. Methylprednisolone dengan makanan (Moderate)
MONITOR: Grapefruit juice may increase the plasma concentrations of orally
administered drugs that are substrates of the CYP450 3A4 isoenzyme. However, the
interaction seems to affect primarily those drugs that undergo significant
presystemic metabolism by CYP450 3A4 (i.e., drugs with low oral bioavailability),
presumably due to the fact that grapefruit juice inhibits primarily intestinal rather
than hepatic CYP450 3A4. Because pharmacokinetic interactions involving
grapefruit juice are often subject to a high degree of interpatient variability, the
extent to which a given patient may be affected is difficult to predict.
MANAGEMENT: Patients who regularly consume grapefruit or grapefruit juice
should be monitored for adverse effects and altered plasma concentrations of drugs
that undergo significant presystemic metabolism by CYP450 3A4. Grapefruit and
grapefruit juice should be avoided if an interaction is suspected. Orange juice is not
expected to interact with these drugs.
3. aspirin dengan valsartan (Moderate)
MONITOR: Nonsteroidal anti-inflammatory drugs (NSAIDs) may attenuate the
antihypertensive effects of angiotensin II receptor antagonists. The proposed
mechanism is NSAID-induced inhibition of renal prostaglandin synthesis, which
results in unopposed pressor activity producing hypertension. In addition, NSAIDs
can cause fluid retention, which also affects blood pressure. Clinical data are
limited.
MONITOR: Concomitant use of NSAIDs and angiotensin II receptor antagonists
may cause deterioration in renal function, particularly in patients who are elderly or
volume-depleted (including those on diuretic therapy) or have compromised renal
function. Acute renal failure may occur, although effects are usually reversible.
Chronic use of NSAIDs alone may be associated with renal toxicities, including

elevations in serum creatinine and BUN, tubular necrosis, glomerulitis, renal

papillary necrosis, acute interstitial nephritis, nephrotic syndrome, and renal failure.
Additionally, in patients with prerenal conditions whose renal perfusion may be
dependent on the function of prostaglandins, NSAIDs may precipitate overt renal
decompensation via a dose-related inhibition of prostaglandin synthesis.
Angiotensin II receptor antagonists can further worsen renal function by blocking the
effect of angiotensin II-mediated efferent arteriolar vasoconstriction, thereby
decreasing glomerular filtration.
MANAGEMENT: Patients receiving angiotensin II receptor antagonists who require
prolonged (greater than 1 week) concomitant therapy with an NSAID should have
blood pressure monitored more closely following initiation, discontinuation, or
change of dosage of the NSAID. Renal function should also be evaluated
periodically during prolonged coadministration. The interaction is not expected to
occur with low doses (e.g., low-dose aspirin) or intermittent short-term
administration of NSAIDs.
4. Bisoprolol dengan valsartan (Moderate)
GENERALLY AVOID: In the Valsartan Heart Failure Trial, the combination of
valsartan with a beta-blocker and an ACE inhibitor was associated with unfavorable
outcomes on morbidity and mortality in heart failure patients. The mechanism is
unknown.
MANAGEMENT: The manufacturer recommends that the triple combination of
valsartan with a beta-blocker and an ACE inhibitor be avoided in heart failure
patients.
5. valsartan food (Moderate)
GENERALLY AVOID: Moderate-to-high dietary intake of potassium, especially salt
substitutes, may increase the risk of hyperkalemia in some patients who are using
angiotensin II receptor blockers (ARBs). ARBs can promote hyperkalemia through
inhibition of angiotensin II-induced aldosterone secretion. Patients with diabetes,
heart failure, dehydration, or renal insufficiency have a greater risk of developing
hyperkalemia.
MANAGEMENT: Patients should receive dietary counseling and be advised to not
use potassium-containing salt substitutes or over-the-counter potassium
supplements without consulting their physician. If salt substitutes are used
concurrently, regular monitoring of serum potassium levels is recommended.
Patients should also be advised to seek medical attention if they experience

symptoms of hyperkalemia such as weakness, irregular heartbeat, confusion,

tingling of the extremities, or feelings of heaviness in the legs.