CML Society of Canada — Drug & Food Interaction Chart 2026
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CML Society of Canada La Société de la Leucémie
Myéloïde chronique du Canada

CML Drug & Food Interaction Reference Chart — Updated 2026

A comprehensive, peer-reviewed reference for known interactions between all approved CML tyrosine kinase inhibitors (TKIs) and co-medications, food, spices, herbs, and natural products. Always review this chart with your healthcare team before making any changes to your medications or supplements.

1st gen: Imatinib (Gleevec®) 2nd gen: Dasatinib (Sprycel®) · Nilotinib (Tasigna®) · Bosutinib (Bosulif®) 3rd gen: Ponatinib (Iclusig®) STAMP inhibitor: Asciminib (Scemblix®)
Drug tag applies to: All TKIs Imatinib Dasatinib Nilotinib Bosutinib Ponatinib Asciminib  |  Tags without colour = applies to the group or class noted inline.
1
DRUGS WITH POTENTIAL TO PROLONG THE QT INTERVAL — use with extreme caution with nilotinib, dasatinib, bosutinib & ponatinib

Anti-arrhythmic drugs

  • Amiodarone
  • Disopyramide
  • Procainamide
  • Quinidine
  • Sotalol
  • Dofetilide
  • Dronedarone

Fluoroquinolone antibiotics ⚠

  • Moxifloxacin — highest QT risk among fluoroquinolones
  • Ciprofloxacin — moderate QT risk + CYP3A4 inhibitor (dual interaction risk)
  • Norfloxacin — moderate QT risk + CYP3A4 inhibitor
  • Levofloxacin — lower QT risk; use with caution
Dual-risk alert — Nilotinib patients: Ciprofloxacin and norfloxacin both prolong QT interval and inhibit CYP3A4, which can increase nilotinib plasma concentrations — compounding QT prolongation risk. The FDA nilotinib prescribing information (black box warning) explicitly advises avoiding concomitant use of QT-prolonging drugs and CYP3A4 inhibitors. ECG and electrolyte monitoring required. Nilotinib ⚠ dual risk

Other drugs

  • Chloroquine / Hydroxychloroquine
  • Halofantrine
  • Clarithromycin
  • Haloperidol
  • Methadone
  • Domperidone
  • Ondansetron (high dose)
  • Antipsychotics (ziprasidone, quetiapine)

Oncologics & other

  • Anthracyclines (cumulative high-dose)
  • Vandetanib
  • Vemurafenib
  • Ribociclib
Asciminib: No clinically relevant QT prolongation effect based on Phase I data. Asciminib
2
CYP3A4 INHIBITORS — may INCREASE TKI plasma concentrations ▲

Antifungals

  • Ketoconazole All TKIs
  • Itraconazole *
  • Fluconazole
  • Voriconazole
  • Posaconazole
  • Terbinafine

Antibiotics

  • Erythromycin
  • Clarithromycin +35% AUC
  • Troleandomycin
  • Telithromycin
  • Ciprofloxacin
  • Norfloxacin

Antivirals (HIV/HCV)

  • Atazanavir
  • Indinavir
  • Nelfinavir
  • Ritonavir
  • Saquinavir
  • Delavirdine
  • Cobicistat
  • Telaprevir

Other

  • Diltiazem
  • Verapamil
  • Amiodarone
  • Nefazodone
  • Fluvoxamine
  • Mifepristone
  • Cimetidine
  • Aprepitant
  • Isoniazid
Asciminib-specific: Also a substrate of UGT2B7/UGT2B17 and BCRP transporter. Itraconazole oral solution (cyclodextrin excipient) unexpectedly decreases asciminib exposure ~40%; capsule form has minimal effect. Clarithromycin increased asciminib AUC ~35%. Asciminib itself is a moderate inhibitor of CYP3A4, CYP2C9, and CYP2C8 — it can increase levels of co-administered substrates (warfarin, midazolam, repaglinide, atorvastatin). Asciminib
3
CYP3A4 INDUCERS — may DECREASE TKI plasma concentrations ▼

Antibiotics / Antifungals

  • Rifampin (rifampicin) All TKIs
  • Rifabutin
  • Griseofulvin

Antivirals

  • Efavirenz
  • Nevirapine
  • Etravirine
  • Lopinavir/ritonavir

Anticonvulsants

  • Carbamazepine
  • Phenytoin
  • Fosphenytoin
  • Phenobarbital
  • Primidone
  • Oxcarbazepine

Other inducers

  • Dexamethasone (high dose)
  • Pioglitazone
  • Troglitazone
  • Modafinil
  • Apalutamide Ponatinib
  • Bosentan Ponatinib
4
DRUGS WHOSE PLASMA CONCENTRATIONS MAY BE INCREASED ▲ by TKIs

Cardiovascular

  • Warfarin All TKIs
  • Amlodipine
  • Diltiazem
  • Felodipine
  • Nifedipine
  • Verapamil
  • Clopidogrel
  • Sildenafil / Tadalafil

Statins (HMG-CoA reductase inhibitors)

  • Atorvastatin +24% Cmax
  • Lovastatin
  • Simvastatin
  • Rosuvastatin (OATP1B substrate)

Immunosuppressants

  • Cyclosporine
  • Tacrolimus
  • Sirolimus

Other substrates

  • Midazolam (CYP3A4) +28%
  • Codeine
  • Acetaminophen
  • Methadone
  • Quetiapine
  • Trazodone
  • Tamoxifen
  • Paclitaxel (Taxol)
  • Vincristine / Irinotecan
  • Dextromethorphan
5
DRUGS WHOSE PLASMA CONCENTRATIONS MAY BE DECREASED ▼ by TKIs
  • Levothyroxine Imatinib
Monitor thyroid function regularly when imatinib is co-prescribed with levothyroxine. Dose adjustments may be needed.
  • Oral contraceptives — effectiveness may be reduced All TKIs
Women of childbearing potential should use additional non-hormonal contraception. All TKIs are teratogenic — do not become pregnant while on treatment.
6
ACID-REDUCING AGENTS — may alter TKI absorption (effects are drug-specific)

Proton pump inhibitors (PPIs)

  • Omeprazole Avoid with Dasatinib
  • Lansoprazole
  • Pantoprazole
  • Esomeprazole
PPIs significantly reduce dasatinib and nilotinib absorption. Avoid concurrent use. PPIs may decrease bosutinib levels — consider short-acting antacids instead. Asciminib and imatinib are minimally affected.

H2 receptor antagonists

  • Ranitidine Caution
  • Famotidine
  • Cimetidine
If acid suppression is needed, H2 blockers may be taken 10 hours before or 2 hours after dasatinib. Minimal effect on asciminib.

Antacids

  • Calcium carbonate Decreases Ponatinib
  • Aluminum/magnesium hydroxide Avoid with Ponatinib
Antacids raise gastric pH and reduce ponatinib bioavailability. Space antacids ≥2 hours from TKI dose where possible. Imatinib and asciminib are unaffected.
7
VACCINES — special considerations during TKI therapy
  • Live virus vaccines — contraindicated All TKIs
  • Flu vaccine / interferon-inducing vaccines — discuss with physician
Immunization during TKI therapy may produce a diminished antibody response. Live attenuated vaccines (MMR, varicella, zoster-live, yellow fever) must not be given during TKI therapy. Inactivated vaccines are generally acceptable. Asciminib maintains antibody-dependent cellular cytotoxicity (ADCC) activity.
8
HERBAL PRODUCTS — known to DECREASE ▼ TKI levels (avoid)
  • St. John's Wort (Hypericum perforatum) — strong CYP3A4 inducer All TKIs
Avoid entirely. St. John's Wort can reduce TKI plasma concentrations by up to 50% via CYP3A4 and P-gp induction, potentially causing treatment failure.

Herbals with possible CYP3A4 induction — avoid

  • Valerian root (Valeriana officinalis)
  • Echinacea (Echinacea purpurea)
  • Ashwagandha (Withania somnifera) — emerging evidence
9
HERBAL PRODUCTS — known to INCREASE ▲ TKI levels (risk of toxicity)
  • Kava-kava (Piper methysticum) — CYP3A4 inhibitor
  • Goldenseal (Hydrastis canadensis) — CYP3A4 inhibitor
  • Cat's claw (Uncaria tomentosa) — CYP3A4 inhibitor
  • Black cohosh (Cimicifuga racemosa)
  • Milk thistle (Silymarin) — may alter CYP3A4/2C9
  • Turmeric / Curcumin supplements — CYP3A4 and P-gp inhibitor at supplement doses; adjuvant use with imatinib studied in CML (monitor levels)
  • Grapefruit seed extract
  • Pomegranate seed extract
  • Piperine / black pepper extract — CYP3A4 inhibitor at concentrated doses
  • Berberine — CYP3A4 inhibitor; limited TKI-specific data
10
HERBAL PRODUCTS — uncertain or bidirectional effects ▲▼ (avoid large quantities; discuss with your team)
  • Ginkgo (Ginkgo biloba)
  • Garlic (Allium sativum)
  • Saw palmetto (Serenoa repens)
  • Siberian ginseng (Eleutherococcus senticosus)
  • Panax ginseng
  • Dong quai (Angelica sinensis)
  • Glucosamine / chondroitin
  • Genistein (isoflavonoid)
  • Green tea (Camellia sinensis) — concentrate/extract form
  • Dandelion, peppermint, chamomile teas (large quantities uncertain)
  • Resveratrol — CYP3A4 modulation reported
More studies are needed to determine exact effects with TKIs. Do not consume large quantities of these products without first discussing with your hematologist or pharmacist.
11
FOODS THAT MAY INCREASE ▲ TKI plasma levels — avoid or limit to normal dietary amounts

Citrus (CYP3A4 inhibition via furanocoumarins)

  • Grapefruit & grapefruit juice All TKIs
  • Pomelo
  • Seville oranges
  • Blood oranges

Other foods

  • Star fruit (Averrhoa carambola) — CYP3A4 inhibitor
  • Pomegranate juice — weak CYP3A4 inhibitor
  • Unfiltered coffee (cafestol) — CYP modulation
  • High-fat meals — reduce asciminib absorption significantly Take fasted

Spices at concentrated / supplement doses

  • Turmeric (curcumin) — CYP3A4/P-gp interaction at supplement doses; culinary amounts likely safe
  • Black pepper (piperine) — significant CYP3A4/P-gp inhibitor at supplement doses; culinary cooking amounts likely safe
Culinary spice use in normal cooking is unlikely to cause clinically significant interactions. Concern arises with concentrated supplements or extracts.
12
FOODS THAT MAY DECREASE ▼ TKI plasma levels — follow your drug-specific food instructions
  • High-fat / high-calorie meals — significantly decrease asciminib exposure Asciminib: always take fasted
  • Food increases nilotinib exposure and QT prolongation risk — must take on empty stomach Nilotinib: always take fasted
  • Fasting significantly reduces bosutinib absorption — must take with food Bosutinib: always take with food
  • Cruciferous vegetables (broccoli, Brussels sprouts) in very high quantities — theoretical CYP3A4 induction; normal dietary amounts are safe
13
DRUG-SPECIFIC HIGHLIGHTS — refer to your prescribing information for a complete list

Nilotinib key interactions

  • Strong QT risk — ECG monitoring required
  • Avoid all food 2h before and 1h after dose
  • Contains lactose — discuss with physician if lactose intolerant

Dasatinib key interactions

  • Contains lactose
  • PPIs significantly reduce absorption — avoid
  • H2 blockers: take dasatinib 10h after or 2h before
  • Pleural effusion risk worsened by fluid-retaining drugs

Bosutinib key interactions

  • Must be taken with food
  • Ketoconazole raises levels >5-fold — avoid combination
  • PPIs decrease levels — use short-acting antacids instead
  • Moderate QT risk — avoid QT-prolonging drugs

Ponatinib key interactions

  • Avoid antacids and gastric pH-raising drugs
  • Strong CYP3A4 inhibitors: reduce starting dose to 30 mg
  • Strong CYP3A4 inducers: avoid co-administration
  • Significant arterial occlusion risk — manage antiplatelet therapy with physician

Asciminib key interactions

  • Administer fasted; high-fat meals significantly reduce absorption
  • Itraconazole oral solution (cyclodextrin) decreases exposure ~40% — avoid; capsule form has minimal effect
  • Inhibits CYP3A4/2C9/2C8 — raises levels of warfarin, midazolam, repaglinide, atorvastatin; monitor carefully
  • Substrate of BCRP and UGT2B7/2B17 — potential interactions with inhibitors of these pathways
  • No clinically significant QT prolongation observed in trials
  • P-gp inhibitors (e.g., quinidine) had minimal effect on asciminib exposure in Phase I studies

Peer-reviewed references & regulatory sources

  1. Hoch M, et al. Clinical Pharmacology of Asciminib: A Review. Clin Pharmacokinet. 2024;63(11):1513–1528. DOI: 10.1007/s40262-024-01428-6
  2. Hoch M, et al. Pharmacokinetics of asciminib in the presence of CYP3A or P-gp inhibitors, CYP3A inducers, and acid-reducing agents. Clin Transl Sci. 2022;15(4):927–939. PMC9283742
  3. Hoch M, et al. Pharmacokinetic drug interactions of asciminib with CYP450 probe substrates midazolam, warfarin, and repaglinide in healthy participants. Clin Transl Sci. 2022;15(6):1557–1569. PMC9199882
  4. Hoch M, et al. Assessment of pharmacokinetic drug interaction of asciminib with atorvastatin in healthy participants. Clin Pharmacol Drug Dev. 2025;14(3). PMC12856970
  5. Breccia M, et al. Drug interactions with tyrosine kinase inhibitors imatinib, dasatinib, and nilotinib. Blood Rev. 2011;25(3). PMID: 20810928
  6. García-Gutiérrez V, et al. Critical review and expert-based recommendations for bosutinib in CML. Front Oncol. 2024;14:1398043. PMC11381280
  7. Marin D, et al. Clinical pharmacokinetics and drug–drug interactions of tyrosine-kinase inhibitors in CML: a clinical perspective. Blood Rev. 2024;64:101143. DOI: 10.1016/j.blre.2024.101143
  8. Pfizer Inc. BOSULIF® (bosutinib) prescribing information. Revised 2023.
  9. Takeda/ARIAD. ICLUSIG® (ponatinib) prescribing information. Revised 2023.
  10. Novartis Pharmaceuticals. SCEMBLIX® (asciminib) prescribing information. 2022.
  11. Bristol Myers Squibb. SPRYCEL® (dasatinib) prescribing information. Revised 2023.
  12. Novartis Pharmaceuticals. TASIGNA® (nilotinib) prescribing information. Revised 2021.
  13. Kunnumakkara AB, et al. Role of turmeric and curcumin in prevention and treatment of chronic diseases: lessons learned from clinical trials. ACS Pharmacol Transl Sci. 2023;6(4):447–518. PMC10111629
  14. Hochhaus A, et al. Asciminib in newly diagnosed chronic myeloid leukemia. N Engl J Med. 2024;391:885–898.
  15. Drug–drug interactions in targeted cancer therapies: a focus on tyrosine kinase inhibitors. Expert Rev Clin Pharmacol. 2025. DOI: 10.1080/17512433.2025.2606258
  16. National CML Society. Drug & Food Interactions Reference. nationalcmlsociety.org (reviewed 2024).

This chart was compiled by the CML Society of Canada (CMLSC) for patient education purposes and reviewed against peer-reviewed literature as of 2026. It does not replace individualized medical advice. Drug interaction profiles evolve — always consult your hematologist or pharmacist before adding any new medication, supplement, herbal product, or making changes to your diet. Patients in Quebec are encouraged to discuss medication management under Bill 31 pharmacist services. © 2026 CML Society of Canada / Société de la Leucémie Myéloïde chronique du Canada.