Answer: D. All of the above.
Grapefruit juice can inhibit CYP3A4 and OAT for up to 24 hours. CYP3A4 and OAT are membrane transporters involved in the metabolism of certain statins. Sweet orange (citrus sinensis) may inhibit OATP, which helps mediate hepatic uptake and facilitates statin metabolism. Tangerines are related to sweet orange and may also inhibit OATP. Patients should either avoid these juices altogether or limit consumption to 60 mL per serving. Separating consumption of these juices from statin administration by 4 hours may also limit the interaction.1
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1. Kellick KA, Bottorff M, Toth PP, The National Lipid Association's Safety Task Force. A clinician's guide to statin drug-drug interactions. J Clin Lipidol. 2014;8:S30-46.
2. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2013;63:2889-2934.
3. US Food and Drug Administration. FDA Drug Safety Communication: interaction between certain HIV or hepatitis C drugs and cholesterol-lowering statin drugs can increase the risk of muscle injury. http://www.fda.gov/Drugs/DrugSafety/ucm293877.htm. Published March 1, 2012. Acessed May 8, 2018.
4. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1 infected adults and adolescents. US Department of Health and Human Services. Available at https://aidsinfo.nih.gov/contentfiles/adultandadolescentgl003093.pdf. Accessed May 18, 2018.