Citrus Bioflavonoids 650 mg by Natural Factors

POSSIBLY INEFFECTIVE

• Hypercholesterolemia. Oral hesperidin does not seem to reduce cholesterol levels. Details: Clinical studies and a meta-analysis of the available clinical research show that taking hesperidin 400-800 mg daily for 4-12 weeks does not affect total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, or triglyceride levels when compared with placebo in healthy and obese individuals with or without mild hypercholesterolemia (94539,102315). However, some preliminary clinical research shows that taking glucosyl hesperidin, a soluble hesperidin derivative, 500 mg daily for 24 weeks modestly lowers serum levels of triglycerides and LDL cholesterol when compared with baseline in patients with both hypercholesterolemia and hypertriglyceridemia, but not in those without hypertriglyceridemia (54800). The validity of this finding is limited by the lack of a comparator group.
• Obesity. Oral hesperidin does not seem to be beneficial for weight loss. Details: A meta-analysis of two clinical trials shows that taking hesperidin for 6-12 weeks does not affect body weight or body mass index (BMI) when compared with placebo, although it may modestly improve waist circumference (105280,105281). The studies included in this analysis were short-term and were not designed to evaluate weight as a primary endpoint. Other clinical research conducted in Japan shows that taking glucosyl hesperidin, a soluble hesperidin derivative, 470 mg orally daily for 12 weeks does not reduce body weight, total fat area, or subcutaneous fat area when compared to baseline in modestly overweight patients (94544). Hesperidin has also been evaluated in combination with green tea extract. One clinical study in overweight individuals shows that taking a combination of glucosyl hesperidin 178 mg and green tea extract, providing epigallocatechin gallate (EGCG) 146 mg, daily for 12 weeks modestly attenuates an increase in weight and BMI when compared with placebo. Sub-group analyses suggest that the greatest effects occurred in individuals less than 50 years of age (108152). It is unclear if these effects are due to hesperidin, green tea extract, or the combination.

INSUFFICIENT RELIABLE EVIDENCE to RATE

• Athletic performance. It is unclear if oral hesperidin is beneficial for improving athletic performance. Details: Small clinical studies in healthy male cyclists show that taking a specific form of hesperidin (Cardiose, HealthTech BioActives) has some benefit on athletic performance. One study shows that taking this form of hesperidin 500 mg once, five hours prior to exercise, improves average power, maximum speed, and total energy when compared with placebo. However, it does not improve peak power, time to peak power, or total oxygen consumption (102312). Taking this form of hesperidin 500 mg daily for 8 weeks modestly improves the highest average power output that can be maintained for one hour and the maximal power during an incremental test when compared with placebo. However, there was no effect on the aerobic or anaerobic ventilatory thresholds, oxygen use, or the times to peak power or maximum speed when compared with placebo (105277).
• Chronic prostatitis and chronic pelvic pain syndrome (CP/CPPS). Although there is interest in using oral hesperidin for CP/CPPS, there is insufficient reliable information about the clinical effects of hesperidin for this condition. There is research evaluating the use of micronized purified flavonoid fraction, which contains small amounts of hesperidin. See Diosmin for more information.
• Chronic venous insufficiency (CVI). Oral hesperidin has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Clinical research shows that taking a specific combination product containing hesperidin methyl chalcone 150 mg, butcher's broom root extract 150 mg, and ascorbic acid 100 mg (Cyclo 3 Fort) usually for 1-3 months may decrease pain, heaviness, cramps, and paresthesia in patients with CVI (37483). There is also research evaluating the use of micronized purified flavonoid fraction, which contains small amounts of hesperidin, for CVI. See Diosmin for more information.
• Cognitive function. Although there is interest in using oral hesperidin for improving cognitive function, there is insufficient reliable information about the clinical effects of hesperidin for this condition.
• Coronary artery bypass graft (CABG) surgery. Although there is interest in using oral hesperidin for patients undergoing CABG surgery, there is insufficient reliable information about the clinical effects of hesperidin for this purpose. There is research evaluating the use of micronized purified flavonoid fraction, which contains small amounts of hesperidin. See Diosmin for more information.
• Diabetes. It is unclear if oral hesperidin is beneficial for diabetes. Details: Clinical research in adults with diabetes shows that taking hesperidin (Swanson Health Products) 500 mg once daily for 6 weeks reduces systolic blood pressure and the mean arterial blood pressure by about 3% and 2.5%, respectively, when compared with placebo. Although this improvement is statistically significant, it is unlikely to be considered clinically significant. Also, hesperidin does not modify levels of fasting blood glucose or measures of insulin resistance (98697,105292). A prospective observational study in patients with type 1 or type 2 diabetes has found that taking a specific product (Flebotrofine, AMNOL Chimica Biologica) containing hesperidin for 3 months is not associated with improvements in HbA1c, cholesterol, or triglyceride levels when compared with baseline. Other ingredients in this product included L-arginine, troxerutin, diosmin, black currant extract, and gotu kola extract (108151). There is also research evaluating the use of micronized purified flavonoid fraction, which contains small amounts of hesperidin, for diabetes. See Diosmin for more information.
• Diabetic retinopathy. Although there is interest in using oral hesperidin for diabetic retinopathy, there is insufficient reliable information about the clinical effects of hesperidin for this condition.
• Hemorrhoids. Oral hesperidin has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Preliminary clinical research in patients with acute hemorrhoidal crisis shows that taking a specific supplement (Triade H, Omikron Italia Srl) containing hesperidin, diosmin, and troxerutin daily for 43 days results in significantly less pain, bleeding, anal itching, and medication use when compared with placebo (93885). This product was given as one sachet of powdered diosmin 300 mg, troxerutin 300 mg, hesperidin 300 mg, and vitamin C 12 mg mixed in water orally three times daily for 3 days, then two sachets daily for 2 days, then one sachet daily for seven days, followed by one tablet containing hesperidin 100 mg, diosmin 300 mg, and troxerutin 300 mg daily for one month (93885). There is also research evaluating the use of micronized purified flavonoid fraction, which contains small amounts of hesperidin, for hemorrhoids. See Diosmin for more information.
• Hypertension. It is unclear if oral hesperidin is beneficial for hypertension. Details: Preliminary clinical research in overweight males with or without hypertension shows that taking hesperidin 136 mg or drinking 250 mL of orange juice containing hesperidin 136 mg twice daily for 4 weeks lowers diastolic, but not systolic, blood pressure by around 5 mmHg when compared with placebo (94543). However, a meta-analysis of the available clinical research shows that taking hesperidin supplements 400-800 mg daily for 4-12 weeks does not reduce systolic or diastolic blood pressure when compared with placebo in healthy and obese individuals with or without hypertension (102315). Due to the mixed populations evaluated in this research, the effect of hesperidin in patients with diagnosed hypertension is unclear.
• Hypertriglyceridemia. It is unclear if oral hesperidin is beneficial for hypertriglyceridemia. Details: Preliminary clinical research in patients with hypercholesterolemia shows that taking glucosyl hesperidin, a soluble hesperidin derivative, 500 mg daily for 6 weeks modestly lowers triglyceride levels when compared with baseline in patients who also have hypertriglyceridemia, but not in those without hypertriglyceridemia. However, glucosyl hesperidin did not lower cholesterol levels; a lower dose of 100 mg daily had no effect on either outcome (105290). Clinical research in a similar population shows that taking glucosyl hesperidin 500 mg daily for 24 weeks reduces triglyceride levels by up to 34% from baseline and modestly reduces levels of low-density lipoprotein cholesterol (54800). The validity of the findings in these studies is limited by the lack of a comparator group.
• Lymphedema. Oral hesperidin has only been evaluated in combination with other ingredients; its effect when used alone is unclear. Details: Clinical research in females with lymphedema due to breast cancer surgery shows that taking three capsules of a specific combination product (Cyclo 3 Fort), which contains hesperidin methyl chalcone 150 mg, butcher's broom root extract 150 mg, and ascorbic acid 100 mg per capsule, three times daily orally for 90 days reduces swelling in the upper arm and forearm and improves mobility and heaviness when compared with placebo (37494). There is also research evaluating the use of micronized purified flavonoid fraction, which contains small amounts of hesperidin, for lymphedema. See Diosmin for more information.
• Metabolic syndrome. It is unclear if oral hesperidin is beneficial for metabolic syndrome. Details: A small clinical study in adults with metabolic syndrome shows that taking hesperidin (Shaanxi Yuantai Biological Technology Co., Ltd) 500 mg twice daily for 12 weeks increases the number of patients who no longer have defined metabolic syndrome by almost two-fold when compared with placebo. There were also modest reductions in fasting blood glucose, triglycerides, and systolic blood pressure, as well as the total number of patients with abdominal obesity, elevated blood pressure, and elevated fasting blood sugar. However, there were no differences in levels of high-density lipoprotein (HDL) cholesterol, diastolic blood pressure, or waist circumference (105288). In another preliminary clinical study using the same product, there were modest reductions in systolic blood pressure and triglyceride levels when compared with no treatment. However, there were no effects on other measures of metabolic syndrome or the overall number of patients with defined metabolic syndrome. When taken in combination with flaxseed 15 grams twice daily, serum concentrations of triglycerides and glucose, as well as systolic blood pressure, were modestly improved when compared with control. The prevalence of individuals with defined metabolic syndrome at the end of treatment was reduced by approximately 77%, which was significant when compared with the control group (105276). These studies may have been too small to detect differences in most endpoints.
• Minor bleeding. Although there is interest in using oral hesperidin for minor bleeding, there is insufficient reliable information about the clinical effects of hesperidin for this purpose. There is research evaluating the use of micronized purified flavonoid fraction, which contains small amounts of hesperidin. See Diosmin for more information.
• Nonalcoholic fatty liver disease (NAFLD). It is unclear if oral hesperidin is beneficial for NAFLD; the available evidence is conflicting. Details: A small clinical trial in adults with NAFLD shows that taking hesperidin 1 gram daily for 12 weeks along with lifestyle modification improves hepatic steatosis as measured by transient elastography when compared with placebo and lifestyle modification. Taking hesperidin also modestly improves total cholesterol, triglyceride, alanine aminotransferase (ALT), and gamma-glutamyl transferase (GGT) levels. However, there were no effects on liver fibrosis or levels of aspartate aminotransferase (AST), fasting blood glucose, insulin, low-density lipoprotein (LDL) cholesterol, or high-density lipoprotein (HDL) cholesterol (102313). Other preliminary clinical research using the same treatment protocol shows that although there were modest reductions in ALT, there was no effect on liver steatosis, liver fibrosis, or other metabolic measures. When used in combination with flaxseed 30 grams daily, levels of fasting blood glucose and a measure of insulin resistance were modestly improved (105275). These studies may have been too small to detect differences in most endpoints.
• Rheumatoid arthritis (RA). It is unclear if oral hesperidin is beneficial for RA. Details: A small clinical study shows that drinking a 100 mL beverage containing alpha-glucosyl hesperidin 3 grams daily orally for 12 weeks might improve symptoms of RA when compared with placebo (54850).
• Varicose veins. Although there is interest in using oral hesperidin for varicose veins, there is insufficient reliable information about the clinical effects of hesperidin for this condition. There is research evaluating the use of micronized purified flavonoid fraction, which contains small amounts of hesperidin, for this purpose. See Diosmin for more information.
• Venous leg ulcers. Although there is interest in using oral hesperidin for venous leg ulcers, there is insufficient reliable information about the clinical effects of hesperidin for this condition. There is research evaluating the use of micronized purified flavonoid fraction, which contains small amounts of hesperidin, for this purpose. See Diosmin for more information. More evidence is needed to rate hesperidin for these uses.

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INSUFFICIENT RELIABLE EVIDENCE to RATE

• Asthma. It is unclear if dietary citrus fruits are beneficial in patients with asthma. Details: There is some evidence that consumption of vitamin C-rich citrus fruits, including sweet orange and others, might improve lung function in people with asthma. However, this is controversial. Some studies show that intake of citrus fruits 1-2 times per week produces significant benefit (6049,6055,6056), while other studies have not found this benefit (6057,6058).
• Common cold. It is unclear if drinking sweet orange juice prevents the common cold. Details: Preliminary clinical research in healthy individuals ages 17 to 25 years suggests that drinking sweet orange juice 180 mL daily for 72 days might decrease the risk of developing common cold-related symptoms (15328).
• Depression. It is unclear if drinking sweet orange juice or using sweet orange essential oil as aromatherapy is beneficial for depression. Details: Preliminary clinical research in adults with depression shows that drinking flavonoid-rich sweet orange juice 190 mL three times daily for 8 weeks modestly improves depression scores when compared to baseline, but not when compared with a low-flavonoid orange drink (110045). Sweet orange has also been studied as part of a combination aromatherapy. A very small clinical study in community-dwelling older adults shows that massage therapy to the upper body with sweet orange, lavender, and bergamot oils twice weekly for 8 weeks improves symptoms of depression in 65% of patients when compared with no intervention. Twice weekly inhalation of the same essential oils via nebulizer, without massage, also improves symptoms of depression in 55% of patients when compared with no intervention (98474).
• Hypercholesterolemia. It is unclear if drinking sweet orange juice improves blood lipid levels. Details: A very small clinical study in hypercholesterolemic patients shows that drinking large amounts of sweet orange juice (750 mL daily for four weeks) seems to increase high-density lipoprotein (HDL) cholesterol by 21% and reduce the ratio of low-density lipoprotein (LDL) to HDL cholesterol by 16% when compared to baseline. This effect was not seen with 250-500 mL of sweet orange juice. Because consumption of this large amount of juice daily provides approximately 20% of the daily energy requirement, this regimen may not be practical (3340).
• Insomnia. Sweet orange essential oil as aromatherapy has only been evaluated in combination with other essential oils; its effect when used alone is unclear. Details: Preliminary clinical research in adults undergoing hemodialysis shows that inhaling aromatherapy with sweet orange and lavender oil nightly before bed for one month improves overall sleep quality by 72% and fatigue by about 78% when compared with no treatment (98508).
• Kidney failure. It is unclear if sweet orange oil massage can improve fatigue or symptoms of restless leg syndrome (RLS) in adults receiving hemodialysis. Details: A small clinical study shows that receiving an 18-minute foot massage with sweet orange oil 1.5% for 3 weeks during hemodialysis sessions modestly improves sleep quality and symptoms of RLS when compared with routine care. However, it does not seem to be more effective than using lavender oil (109859).
• Kidney stones (nephrolithiasis). It is unclear if drinking sweet orange juice is beneficial for preventing kidney stones. Details: Consuming 400 mL of sweet orange juice three times a day, providing a total of 100 mEq of citrate daily, increases urinary pH and urinary citrate levels (15171). Theoretically, this might reduce kidney stone formation in patients with calcium nephrolithiasis. However, this outcome has not been evaluated in clinical research.
• Obesity. It is unclear if drinking sweet orange juice or taking oral sweet orange extract improves weight loss or other metabolic parameters in adults with overweight or obesity. Most studies suggest that any effects are unlikely to be considered clinically relevant. Details: Some preliminary clinical research in adults with overweight or obesity shows that taking a specific sweet orange extract (Morosil, Bionap S.R.L.) 400 mg orally once daily for six months reduces waist circumference, body weight, fat mass, and body mass index (BMI) by 2% to 5% when compared with placebo (110046). However, other preliminary clinical research in this population shows that drinking red sweet orange juice 750 mL daily for 8 weeks does not reduce body weight or BMI when compared with baseline (92309). A meta-analysis of clinical research in adults, most of whom were overweight or obese at baseline, shows that drinking 250-750 mL of various types of sweet orange juice daily for 2-12 weeks does not reduce body weight, BMI, waist circumference, or body fat percentage (BFP) when compared with control groups, which included either no supplementation, pomegranate juice, or exercise (107853). The validity of this meta-analysis is limited due to the population heterogeneity and variety of orange juice formulations and controls utilized. Some clinical studies have also evaluated sweet orange juice for improving cardiovascular risk factors in overweight and obese adults. Although some research has shown benefit, not all research agrees (110046,110047). A meta-analysis of randomized clinical trials in adults with overweight or obesity shows that drinking sweet orange juice 250-600 mL daily for 2-13 weeks modestly increases high-density lipoprotein cholesterol levels and decrease average systolic blood pressure by 1 mmHg when compared with control. However, drinking sweet orange juice does not affect other blood lipid levels, blood glucose levels, or markers of insulin resistance (110048). The validity of this study is limited by high heterogeneity and a small sample size. In addition, these improvements are unlikely to be considered clinically relevant. Sweet orange extract has also been studied in combination with other ingredients. Some clinical research in overweight adults shows that taking a specific combination product (Sinetrol, Fytexia) 450-700 mg twice daily containing sweet orange, blood orange, and grapefruit extracts for 12 weeks reduces body weight, BFP, and BMI when compared with placebo or baseline (95517,95518). It is unclear if these effects are due to sweet orange, other ingredients, or the combination.
• Pre-procedural anxiety. It is unclear if inhaling sweet orange essential oil as aromatherapy reduces anxiety before surgeries or invasive procedures. Details: A small, low-quality study suggests that inhaling the scent from 3 drops of sweet orange essential oil applied to a cotton ball for 5 minutes modesty reduces anxiety and pain scores in patients undergoing needle insertion for hemodialysis when compared with performing a breathing exercise for 3 minutes (105455).
• Prostate cancer. It is unclear if drinking sweet orange juice reduces prostate cancer risk. Details: Observational research has found that increasing dietary intake of sweet orange or sweet orange juice is not associated with a reduced risk of developing prostate cancer (15172).
• Stress. It is unclear if inhaling sweet orange essential oil as aromatherapy is beneficial for stress. Details: Preliminary clinical research shows that using up to 10 drops of sweet orange essential oil as aromatherapy helps prevent some anxiety and tension associated with stressful tasks when compared with control (90505). More evidence is needed to rate sweet orange for these uses.

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LIKELY SAFE ...when used orally in amounts found in foods.

POSSIBLY SAFE ...when supplements are used orally and appropriately, short-term. Doses of up to 3 grams daily have been used with apparent safety for up to 3 months (37494,54850,94544,105275,105276).

PREGNANCY AND LACTATION: LIKELY SAFE
when used orally in amounts found in foods.

PREGNANCY AND LACTATION: POSSIBLY SAFE
when used orally in doses of up to 100 mg daily for 30 days in combination with diosmin. Some evidence suggests that taking this combination may be associated with placental insufficiency when used during the third trimester of pregnancy; however, the combination does not seem to induce fetal abnormalities, retard fetal growth, increase the risk of intrauterine death, or affect birth weight. Also, when breastfeeding, this combination does not seem to affect infant growth or feeding (54970).

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LIKELY SAFE ...when sweet orange juice or fruit is used orally in amounts commonly found in foods (1310,3340,15171,92309).

POSSIBLY SAFE ...when the essential oil of sweet orange is inhaled as aromatherapy, short-term (35735,58060,90505,105455). There is insufficient reliable information available about the safety of sweet orange peel when used orally.

CHILDREN: LIKELY SAFE
when sweet orange juice or fruit is used orally in amounts commonly found in foods.

CHILDREN: POSSIBLY UNSAFE
when the sweet orange peel is used orally in excessive amounts. There have been reports of intestinal colic, convulsions, and death in children given large amounts of sweet orange peel (11).

PREGNANCY AND LACTATION: LIKELY SAFE
when sweet orange juice or fruit is used orally in amounts commonly found in foods (1310,3340).

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ANTICOAGULANT/ANTIPLATELET DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, hesperidin may increase the risk of bleeding if used with anticoagulant or antiplatelet drugs.  Details Animal research suggests that hesperetin, a bioflavonoid aglycone derivative of hesperidin, may have antiplatelet activity (54822).

ANTIHYPERTENSIVE DRUGS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, taking hesperidin with antihypertensive drugs might increase the risk of hypotension.  Details Some clinical and animal research shows that hesperidin can decrease blood pressure (54851,94543,98697,105278). However, other clinical research shows that hesperidin does not affect blood pressure (102315).

CELIPROLOL (Celicard) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, hesperidin may decrease the levels and clinical effects of celiprolol.  Details Animal research shows that concomitant use of hesperidin may reduce the plasma area under the curve of celiprolol by up to 75% (91760). This effect has not been reported in humans.

CNS DEPRESSANTS Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, concomitant use with CNS depressants may cause additive sedative effects.  Details Animal studies show that hesperidin has sedative effects, due to opioid receptor activity (54841) and can increase sedation when used with diazepam (54789). This effect has not been reported in humans.

DILTIAZEM (Cardizem, others) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, hesperidin may increase the levels and clinical effects of diltiazem.  Details Animal research suggests that hesperidin may enhance the bioavailability of diltiazem, increasing the plasma area under the curve of diltiazem by up to 65.3% (91761). This effect has not been reported in humans.

P-GLYCOPROTEIN SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = D Theoretically, hesperidin might inhibit P-glycoprotein-mediated drug efflux and potentially increase levels of drugs that are substrates of P-glycoprotein.  Details In vitro research shows that hesperidin can inhibit P-glycoprotein efflux (54908). This effect has not been reported in humans.

VERAPAMIL (Calan, others) Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Theoretically, hesperidin might increase the levels and clinical effects of verapamil.  Details Animal research suggests that hesperidin may enhance the bioavailability of verapamil, increasing the plasma area under the curve of verapamil by 96.8% (91762). This effect has not been reported in humans

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CELIPROLOL (Celicard) Interaction Rating = Major Do not take this combination. Severity = Moderate •  Occurrence = Likely •  Level of Evidence = B Consuming sweet orange with celiprolol can decrease oral absorption of celiprolol.  Details A pharmacokinetic study in healthy volunteers shows that celiprolol levels, after a single dose of 100 mg, are decreased by up to 90% in people who drink sweet orange juice 200 mL three times daily. It's not known if lower consumption of sweet orange juice will have the same effect. Theoretically, this occurs due to short-term inhibition of organic anion transporting polypeptide (OATP) (12115,17603,17604). Recommend separating drug administration and consumption of sweet orange by at least 4 hours (17603,17604).

FEXOFENADINE (Allegra) Interaction Rating = Moderate Be cautious with this combination. Severity = Mild •  Occurrence = Likely •  Level of Evidence = B Consuming sweet orange juice with fexofenadine can decrease oral absorption of fexofenadine.  Details Clinical research shows that coadministration of sweet orange juice 1200 mL decreases bioavailability of fexofenadine by about 72% (7046,17604). In an animal model, sweet orange juice decreased bioavailability of fexofenadine by 31% (17605). Fexofenadine manufacturer data indicates that concomitant administration of sweet orange juice and fexofenadine results in larger wheal and flare sizes in research models. This suggests that sweet orange reduces the clinical response to fexofenadine (17603). Theoretically, this occurs due to short-term inhibition of organic anion transporting polypeptide (OATP) (7046). Recommend separating drug administration and consumption of sweet orange by at least 4 hours (17603,17604).

IVERMECTIN (Stromectol, others) Interaction Rating = Major Do not take this combination. Severity = Moderate •  Occurrence = Likely •  Level of Evidence = B Consuming sweet orange juice with ivermectin can decrease the oral absorption of ivermectin.  Details A pharmacokinetic study in healthy volunteers shows that taking ivermectin orally with sweet orange juice 750 mL over 4 hours reduces the bioavailability of ivermectin. This effect does not seem to be related to effects on P-glycoprotein. The effect on ivermectin is more pronounced in males compared to females (12154).

ORGANIC ANION-TRANSPORTING POLYPEPTIDE SUBSTRATES (OATP) Interaction Rating = Major Do not take this combination. Severity = Moderate •  Occurrence = Likely •  Level of Evidence = B Consuming sweet orange juice can decrease oral absorption of OATP substrates. Separate administration by at least 4 hours.  Details Clinical research shows that consuming sweet orange juice inhibits OATP, which reduces bioavailability of oral drugs that are substrates of OATP (17603,17604). For example, sweet orange juice decreases bioavailability of fexofenadine, a substrate of OATP, by about 72% and of celiprolol, another OATP substrate, by up to 90% (7046,12115). Since sweet orange juice seems to affect OATP for a short time, recommend separating drug administration and consumption of sweet orange juice by at least 4 hours (17603,17604).

P-GLYCOPROTEIN SUBSTRATES Interaction Rating = Moderate Be cautious with this combination. Severity = High •  Occurrence = Possible •  Level of Evidence = B Sweet orange juice seems to modulate P-glycoprotein (P-gp), which might affect the blood levels of P-gp substrates.  Details Animal and in vitro research suggest that orange juice extract inhibits drug efflux by P-gp, increasing absorption and levels of P-gp substrates (12116,15327). In contrast, pharmacokinetic research in humans shows that drinking large amounts of sweet orange juice decreases absorption and levels of the P-gp substrate celiprolol. This suggests that orange juice actually induces drug efflux by P-gp or affects drug levels by another mechanism such as inhibiting the gut drug transporter called organic anion transporting polypeptide (OATP) (7046,12115). Until more is known, sweet orange juice should be used cautiously in people taking P-gp substrates.

PRAVASTATIN (Pravachol) Interaction Rating = Major Do not take this combination. Severity = Moderate •  Occurrence = Likely •  Level of Evidence = B Consuming sweet orange juice with pravastatin can increase the absorption of pravastatin.  Details A small pharmacokinetic study in healthy volunteers shows that consuming sweet orange juice 800 mL over 3 hours, including before, during, and after taking pravastatin 10 mg, increases pravastatin levels by about 149%, without affecting pravastatin elimination. Theoretically this effect might be due to modulation of organic anion transporting polypeptides (OATPs) by sweet orange juice (14348). Sweet orange juice does not seem to affect simvastatin levels, but it is not known if sweet orange affects any of the other statins.

QUINOLONE ANTIBIOTICS Interaction Rating = Moderate Be cautious with this combination. Severity = Moderate •  Occurrence = Possible •  Level of Evidence = D Calcium-fortified sweet orange juice might reduce quinolone absorption.  Details Calcium binds to quinolones in the gut. Theoretically, the calcium in certain fortified orange juices can also bind to quinolone antibiotics and reduce their absorption and levels (4412,10339,13714,21638,38570).

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General ...Orally, hesperidin is generally well tolerated.

Dermatologic ...A case of recurrent allergic dermatitis was reported in a 70-year-old female with no known allergies who applied topical hesperidin methyl chalchone (94538).

Immunologic ...A case of recurrent allergic dermatitis was reported in a 70-year-old female with no known allergies who applied topical hesperidin methyl chalchone (94538).

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General ...Orally, sweet orange juice or fruit seem to be well tolerated. Large amounts of sweet orange peel may be unsafe, especially for children. When inhaled, sweet orange essential oil seems to be generally well tolerated.

Gastrointestinal ...There have been reports of intestinal colic in children following ingestion of large amounts of sweet orange peel (11).

Neurologic/CNS ...There have been reports of convulsions in children following ingestion of large amounts of sweet orange peel (11).

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