Skip to main content
NCBI home page
PLOS One logoLink to PLOS One
. 2026 Mar 27;21(3):e0346144. doi: 10.1371/journal.pone.0346144

Drug–food and drug–alcohol interactions: Pharmacists’ knowledge gaps and patient safety concerns in the United Arab Emirates

Taima Qudah 1,2, Leen Fino 3, Razan I Nassar 3, Suhad Abumueis 4,*
Editor: Mohammed Zawiah5
PMCID: PMC13028502  PMID: 41894387

Abstract

Pharmacists play a critical role in promoting medication safety through patient counselling and identification of potential interactions. However, knowledge regarding drug–food interactions (DFIs) and drug–alcohol interactions (DAIs) among community pharmacists in the United Arab Emirates (UAE) has not been previously examined. This cross-sectional study assessed pharmacists’ knowledge of DFIs, DAIs, and drug–food administration timing, and identified factors associated with higher knowledge levels using a validated self-administered 24-items questionnaires. The survey assessed sociodemographic and professional characteristics, knowledge of DFIs, DAIs, and drug-food timing. Descriptive statistics and multiple linear regression analyses were performed using SPSS v28.0 to determine predictors of total knowledge scores. Pharmacists demonstrated moderate knowledge, with mean scores of 8.62/12 for DFIs, 5.84/12 for drug–food timing, and 4.70/6 for DAIs (total score 19.16/30). High awareness was observed for interactions such as caffeine–diazepam (76.3%) and methotrexate–alcohol (81.0%), whereas only 25.9% identified potassium-rich foods’ interaction with spironolactone. Higher knowledge scores were associated with being male (p < 0.001), aged 20–29 years (p = 0.041), having ≥6 years of experience (p = 0.004), and higher self-perceived knowledge (p < 0.001). These findings highlight important knowledge gaps that may affect patient safety. Targeted continuing education and integration of DFI/DAI content into pharmacy curricula are recommended to strengthen counselling practices and improve medication safety outcomes.

Introduction

The interaction between food, alcohol, and medications is a crucial yet often overlooked aspect of patient safety. Food has traditionally been valued for its nutritional content as well as its ability to prevent and treat diseases [1]. However, it has the potential to alter drug pharmacokinetics and pharmacodynamics, leading to drug–food interactions (DFIs) [2]. The U.S. Food and Drug Administration (FDA) defines DFIs as situations in which food or beverages modify the absorption, metabolism, distribution, or excretion of drugs, thereby influencing therapeutic efficacy and safety [3–5].

Similarly, drug-alcohol interactions (DAIs) pose a substantial concern, since their combination can lead to considerable adverse effects or a marked reduction in the efficacy of the treatments involved [6]. Although alcohol consumption in the United Arab Emirates is regulated, evidence indicates that alcohol use remains present and represents a public health concern in the country [7], underscoring the importance of awareness of potential drug–alcohol interactions in clinical practice. For example, Interactions between alcohol and antihistamines or nonsteroidal anti-inflammatory medicines (NSAIDs) may increase the risk of internal bleeding and respiratory complications. Alcohol may also cause life-threatening cardiovascular complications when combined with monoamine oxidase inhibitors (MAOIs) [6]. Likewise, drinking alcohol while taking psychiatric or antihypertensive drugs may result in hepatic toxicity, heart rate fluctuations, fainting, and drowsiness [6].

Drug-food Interactions and DAIs are common and clinically significant, contributing to hospitalizations, toxicity, and increased healthcare costs, particularly among older adults [8,9]. Grapefruit juice, for instance, significantly increases medication exposure and the risk of adverse effects by inhibiting CYP3A enzymes [3,10,11]. While excessive intake of vitamin K–rich foods diminishes warfarin’s safety and effectiveness [6,12]. Another well-documented example is the interaction between tyramine-rich meals and MAOIs, which can cause fatal hypertensive crises [6,12]. Despite the existence of well-characterized examples, awareness among healthcare professionals remains suboptimal.

Pharmacists, as accessible healthcare providers, are uniquely positioned to identify and prevent harmful interactions through patient counselling and medication review [13]. According to international guidelines, healthcare providers should proactively detect and avoid potentially harmful interactions and give patients individualized dietary guidance [3,14]. Nevertheless, global evidence indicates that pharmacists’ knowledge of DFIs and DAIs varies widely and is frequently inadequate [15–18].

To date, there haven’t been many studies that evaluate pharmacists’ understanding of DFIs and DAIs, and none that involve community pharmacists in the United Arab Emirates (UAE). Given their central role in patient education and medication safety, assessing their knowledge is essential. Guided by the premise that pharmacists’ demographic and professional characteristics may influence their knowledge and counselling practices, we hypothesized that knowledge levels would vary according to age, gender, and years of experience. Identifying these variations may help inform targeted educational strategies and professional development initiatives to enhance medication safety. Therefore, this study aimed to evaluate the knowledge of community pharmacists in UAE regarding DFIs and DAIs, and the timing of drug administration with respect to food, as well as to determine the variables associated with their levels of knowledge.

Method

Ethical considerations

In this study, human participants were prospectively recruited. The recruitment period was conducted between March 1 and July 31, 2025. Eligible participants were registered pharmacists holding at least a bachelor’s degree in pharmacy and currently employed in community pharmacy practice in the United Arab Emirates. Pharmacy interns, students, and hospital pharmacists were excluded.

All participants provided informed consent prior to participation. Written informed consent was obtained electronically through the survey platform before respondents could proceed to the questionnaire. Participation was voluntary and anonymous, with no collection of personal identifiers or geolocation data. For this study, as all participants were adults, consent from parents or guardians was not applicable. The study protocol, including the consent process, was reviewed and approved by the Ethics Committee of Al Ain University (Ref. No.: COP/AREC/AD/14).

Study design and setting

A validated, cross-sectional online survey was conducted to assess community pharmacists’ knowledge of drug–food interactions (DFIs), drug–alcohol interactions (DAIs), and the timing of drug administration with respect to food in the United Arab Emirates (UAE). The study targeted licensed pharmacists employed in community pharmacies across all seven emirates.

Study population and sampling

Eligible participants were registered pharmacists holding at least a bachelor’s degree in pharmacy (or higher qualification) who were currently employed in community pharmacy practice. Pharmacy interns, students, and hospital pharmacists were excluded.

To collect data, the questionnaire was uploaded to Google Forms, an online survey platform. The inclusion criteria for the respondents were holding a bachelor’s degree in pharmacy or having a higher educational qualification. An invitation to participate in the study reached the target population online, using the social media platforms of pharmacists’ professional groups. This convenience-based online recruitment approach may have preferentially attracted pharmacists who are more professionally engaged or academically inclined, potentially introducing selection bias. The invitation included a brief description of the study and a link to the survey. Participants were informed that the survey was anonymous, no personal identifiers or geolocation data were collected. All responses were kept confidential. The completion of the questionnaire was voluntary, and participants could withdraw from the study at any time. A minimum sample size of 381 participants was recommended, according to the RaoSoft® calculator, based on a margin of error of 5%, confidence level of 95%, population size: 11,153 registered pharmacists In UAE [14] and a response distribution of 50%. The number of respondents included in this study was 401 registered community pharmacists.

Instrument development and validation

The study instrument was developed following an extensive review of the literature on pharmacists’ knowledge of DFIs and DAIs [17,19,16]. Questions were selected based on their comparability with prior validated tools and relevance to UAE pharmacy practice. The preliminary version was reviewed by three academic pharmacists and two community pharmacy practitioners to ensure clarity, content validity, and applicability.

The questionnaire was pilot tested among 20 pharmacists; feedback was used to refine question wording and structure. Data from the pilot phase were excluded from the final analysis. Internal consistency reliability was confirmed using Cronbach’s alpha (α = 0.77), indicating acceptable reliability.

Study instrument

The final questionnaire contained 45 items divided into four sections:

  1. Sociodemographic and professional characteristics (15 items): including gender, location, education level, type of pharmacy, years of experience, number of staff, presence of telepharmacy, and participation in DFI-related events.

  2. Knowledge of DFIs (12 items): assessing awareness of well-known food–drug interactions using “Yes/No” response options.

  3. Knowledge of drug–food timing (12 items): respondents indicated appropriate timing (e.g., 30 minutes before meal, with meal, two hours after meal, or regardless of food).

  4. Knowledge of DAIs (6 items): pharmacists indicated whether alcohol interacts with listed medications (“Yes” for known interaction, “No” for none).

Additionally, pharmacists were asked about their main sources of DFI information, and their perceptions of which patient groups are most susceptible to DFIs.

The questionnaire primarily assessed factual knowledge using closed-ended items to ensure standardization and objective scoring across respondents. While this approach allows efficient evaluation of baseline knowledge, it may not fully reflect real-world counselling behaviors or clinical decision-making.

The full questionnaire and anonymized raw dataset are provided as Supporting Information files (S1 Questionnaire and S1 Data).

Data collection

The final survey was uploaded on Google Forms to facilitate nationwide participation. The invitation link, including a brief description of the study, was distributed through pharmacists’ professional groups and online platforms. Responses were stored securely and automatically recorded, ensuring confidentiality.

All survey questions were mandatory to prevent missing data. Incomplete questionnaires were excluded from analysis.

Scoring and outcome measures

Each correct knowledge response was scored as “1,” and incorrect or “unsure” responses were scored as “0.” Total knowledge scores ranged from 0 to 30, with higher scores indicating better knowledge. Subscale scores were also calculated for each domain: DFIs (0–12), DAIs (0–6), and drug–food timing (0–12).

All items were weighted equally to maintain consistency and comparability with previous knowledge-based surveys. However, we acknowledge that different interactions may carry varying levels of clinical risk, and future research could consider risk-based weighting or case-based assessment approaches.

Statistical analysis

After data collection, the survey responses were coded and input into a customized database using the Statistical Package for the Social Sciences (SPSS), Version 28.0 (IBM Corp., Armonk, New York, USA). Descriptive results were presented using the mean and standard deviation for the continuous variables, while the qualitative variables were presented as frequencies and percentages.

Independent-samples t-tests were conducted to compare mean knowledge scores across binary demographic and professional variables, including gender, age group, geographical location, pharmacy type, and years of experience.

Variables with p < 0.25 in univariate analysis were subsequently entered into a multiple linear regression model to identify independent predictors of total knowledge scores. Multicollinearity was assessed prior to model inclusion. Statistical significance was set at p < 0.05.

Results

Demographic characteristics

A total of 401 pharmacists were recruited in the current study, with more than half being females (56.9%). Most participants were aged 20–39 years (44.4% aged 20–29; 45.1% aged 30–39). Most of the participants resided in Abu Dhabi (63.1%), followed by Dubai (23.2%). A high percentage of the participants (97.3%) held a Bachelor of Pharmacy degree (Table 1).

Table 1. Demographic characteristics of pharmacists (n = 401).

Parameter n (%)
Gender
Male 173 (43.1)
Female 228 (56.9)
Age
20-29 years 178 (44.4)
30-39 years 181 (45.1)
40-49 years 28 (7.0)
50-59 years 10 (2.5)
>60 years 4 (1.0)
Emirate
Abu Dhabi 253 (63.1)
Ajman 14 (3.5)
Dubai 93 (23.2)
Ras Al Khaimah 2 (0.5)
Sharjah 37 (9.2)
Umm Al-Quwain 2 (0.5)
Nationality
Emirati (United Arab Emirates) 1 (0.2)
Syrian 43 (10.7)
Jordanian 35 (8.7)
Palestinian 16 (4.0)
Egyptian 134 (33.4)
Sudanese 22 (5.5)
Indian 95 (23.7)
Filipinos 18 (4.5)
Pakistani 17 (4.2)
British (UK)
1 (0.2)
Iranian 4 (1.0)
Iraqi 10 (2.5)
Bangladeshis 4 (1.0)
Other 1 (0.2)
Educational level
Bachelor of Pharmacy 390 (97.3)
Doctor of Pharmacy (Pharm D) 5 (1.2)
Postgraduate studies 6 (1.5)
Where do you practice?
Chain Pharmacy 264 (65.8)
Individual Pharmacy 137 (34.2)
How many years have you been practicing?
≥ 2 years 80 (20.0)
3-5 years 207 (51.6)
6-10 years 82 (20.4)
11-15 years 25 (6.2)
>15 years 7 (1.7)
Do you think you have enough information about food-drug interactions?
No 117 (29.2)
Yes 284 (70.8)
Open in a new tab

In terms of practice setting, about two-thirds of the study’s participants were practicing in chain pharmacies, while 34.2% reported practicing in individual pharmacies. Years of practice showed variations; more than half of the pharmacists (51.6%) had 3–5 years, 20.4% had 6–10 years, and 20.0% had ≥ 2 years. Pharmacists were asked to self-assess their personal information about DFIs; 70.8% reported sufficient knowledge, while 29.2% indicated a lack of knowledge in that area (Table 1).

Regarding the pharmacy work side, the majority of the participants reported that their pharmacy offers teleservices (96.5%). In addition, 87.0% of the participants reported that the number of licensed staff per shift in the pharmacy is three or fewer, while 13.0% reported having more than three pharmacists in each shift.

Study participants were asked about the age group that is most susceptible to food-drug interactions (Fig 1). The Elderly were reported the most (78.8%), while children were reported the least (23.4%).

Fig 1. Most susceptible age group to food–drug interactions according to participants (n = 401).

Fig 1

Open in a new tab

Study participants were asked about their main source of knowledge about food-drug interactions (Fig 2). University education was reported the most (89.8%), while published literature was reported the least (23.7%).

Fig 2. Main sources of knowledge about food–drug interactions among participants (n = 401).

Fig 2

Open in a new tab

About 39.0% of the study participants reported that it is mandatory to attend conferences, workshops, seminars, or courses related to drug-food interaction. Regarding the number of such events they had attended, 31.4% reported attending 1–2 events, 22.7% reported attending 3–5 events, and 7.0% reported attending more than five events. On the other hand, 38.9% never participated in any related events.

Knowledge of drugs-food interactions

Fig 3 shows the percentages of correct compared to incorrect answers to the 12 knowledge items on drug-food interactions. Eleven of the items were answered correctly by more than half of the participants. The highest percentage of correct answers (76.3%) was on “Does Caffeine consumption affect the efficacy of Diazepam?”.This was followed by “Do protein-rich foods affect the efficacy of levodopa?”, and “Does Cauliflower consumption affect the efficacy of Levothyroxine?” (74.6%, and 74.3%, respectively).

Fig 3. Participants’ responses to 12 items assessing knowledge of drug–food interactions (n = 401).

Fig 3

Open in a new tab

The following four more items were answered correctly by 74.1%− 73.6% of the participants; “Does the wheat bran diet affect the efficacy of Digoxin?”, “Does milk affect the efficacy of Tetracycline”? “Patients taking Theophylline should avoid excessive coffee and tea”, and “Patients taking Monoamine Oxidase Inhibitors (MAOIs) should avoid eating aged cheeses”. In addition, taking Atorvastatin with grapefruit was answered correctly by 69.3%, whereas taking Amiodarone with grapefruit was answered correctly by 68.8%.

On the other hand, the only question that was answered incorrectly by most of the pharmacists was “Patients should avoid taking Spironolactone with food rich in Potassium”, as only 25.9% knew that those patients should avoid potassium-enriched foods.

Analysis of the drug-food interaction items revealed that the pharmacists had a mean score of 8.62 (SD = 3.09), with a minimum score of 2 out of 12, and a maximum score of 12. Notably, more than one-third of the pharmacists (38.7%) answered all the items correctly, achieving a score of 12.

Knowledge of drug-food timing

Fig 4 shows the participants responses to the 12 items assessing knowledge about the timing of drug intake with respect to food. The highest percentage of correct answers was for “Best time to take Omeprazole with respect to food”, with 67.6% of the pharmacists correctly identifying that it should be taken within 30 minutes before a meal. This was followed by “Best time to take Glipizide with respect to food”, with 62.1% of the pharmacists correctly identifying that it should be taken within 30 minutes before a meal. Similarly, 61.8% of the participants correctly recognized that Levothyroxine should be taken on an empty stomach, preferably 30 minutes before a meal.

Fig 4. Participants’ responses to 12 items assessing knowledge of drug–food timing (n = 401).

Fig 4

Open in a new tab

For other medications (Fig 4), participants correctly identified that Metformin, NSAIDs, Isotretinoin, Calcium carbonate supplements, and Griseofulvin should be taken with a meal (58.4%, 55.6%, 54.9%, 54.1%, and 53.1%, respectively).

Conversely, low percentages of correct answers were reported for Erythromycin stearate and Methotrexate (Fig 4).

Analysis of the knowledge about the timing of drug intake with respect to food revealed a mean score of 5.84 (SD = 3.52), with scores ranging from 0 to 11 out of 12. Although no participant correctly identified the timing for all medications; more than one-third of the pharmacists (37.4%) answered 11 out of 12 items correctly.

Knowledge of drugs-alcohol interactions

Fig 5 illustrates the pharmacists’ responses to the 6 items addressing drug-alcohol interactions. Regarding the correct answers, the highest recognition percentage was for Methotrexate and alcohol interaction, with 81.0% of pharmacists identifying it correctly. This was closely followed by Warfarin and alcohol interaction, which was acknowledged by 79.6% of participants.

Fig 5. Participants’ responses to 6 items assessing knowledge of drug–alcohol interactions (n = 401).

Fig 5

Open in a new tab

Additionally, 78.3% of the participants were aware of the interaction between Isoniazid and alcohol. This percentage was also the same for Antihistamine and alcohol (Fig 5). Furthermore, more than three-quarters of the participants recognized the interaction between alcohol, and Metformin (76.8%), as well as alcohol and Paracetamol (76.1%).

Analysis of the knowledge about addressing drug-alcohol interactions revealed a mean score of 4.70 (SD = 2.13), with scores ranging from 0 to 6 out of 6. Notably, more than two-thirds of the pharmacists (68.3%) answered correctly all items about alcohol interaction.

Participant’s total knowledge scores

Exploring the results from another perspective, pharmacists had a mean total knowledge score of 19.16 (SD = 7.39) out of a possible 30, with individual scores ranging from 7 to 28. Although no participant achieved a perfect score of 30, 34.9% of pharmacists scored 28, indicating that a substantial proportion had near-maximal knowledge (Fig 6).

Fig 6. Distribution of total knowledge scores among participants (n = 401).

Fig 6

Open in a new tab

Univariate analysis using independent-samples t-tests identified several demographic factors associated with knowledge scores. Males demonstrated significantly higher total knowledge scores than females (22.54 ± 7.27 vs. 16.60 ± 6.40; mean difference = 5.94; p < 0.001). Pharmacists residing in Abu Dhabi also had higher scores compared with those from other emirates (20.57 ± 7.16 vs. 16.77 ± 7.20; mean difference = 3.90; p = 0.038). Similarly, pharmacists with ≥6 years of experience showed higher knowledge scores than those with ≤5 years of experience (20.67 ± 7.79 vs. 18.57 ± 7.16; mean difference = 2.10; p = 0.001).

No significant differences were observed by age group (19.66 ± 7.15 vs. 18.77 ± 7.57; mean difference = 0.89; p = 0.232) or practice setting (19.63 ± 7.48 vs. 18.28 ± 7.16; mean difference = 1.35; p = 0.164).

According to the multiple linear regression analysis, the total knowledge score was significantly affected by gender, age, years of experience, and whether the participants who self-assessed themselves as well-informed about food-drug interactions (Table 2). Specifically, male pharmacists (p-value <0.001), those aged 20–29 years (p-value = 0.041), pharmacists with ≥6 years of experience (p-value = 0.004), and those who considered themselves well-informed about food-drug interactions (p-value<0.001) demonstrated higher total knowledge scores compared to other participants.

Table 2. Factors associated with total knowledge scores among participants (n = 401).

Parameter Total Score
Beta P-value# Beta P-value$
Gender
 • Male Reference
 • Female −0.399 <0.001 −0.428 <0.001
Age
 • 20–29 years Reference
 • ≥ 30 years −0.060 0.228 −0.091 0.041
Emirate
 • Abu-Dhabi Reference
 • Others −0.248 <0.001 −0.073 0.123
Practice place
 • Chain pharmacy Reference
 • Individual pharmacy −0.087 0.083 0.053 0.246
Years of experience
 • 0–5 years Reference
 •  ≥ 6 years 0.128 0.010 0.138 0.004
Do you think you have enough information about food-drug interactions?
 • No Reference
 • Yes 0.404 <0.001 0.390 <0.001
Open in a new tab

#: Using simple linear regression, $: Using multiple linear regression, *Significant at 0.05 significance level

Discussion

This study evaluated the knowledge and awareness of pharmacists in the United Arab Emirates UAE regarding drug-food and drug-alcohol interactions. To our knowledge, this is the first study addressing pharmacists’ knowledge of DFIs/DAIs conducted in the UAE. Although the study design was cross-sectional and descriptive in nature, it provides essential baseline data regarding pharmacists’ knowledge in a region where such evidence has been lacking. Establishing this baseline is a necessary first step for designing targeted educational and interventional strategies aimed at improving patient safety. The results of this study indicate that community pharmacists in the UAE have an overall moderate level of knowledge. Scoring 19 out of 30 on average, which aligns with the findings of colleagues in Palestine and Jordan [16,20] suggesting that, despite pharmacists’ critical role in maintaining medication safety, there are still gaps in their understanding of clinically significant interactions.

Pharmacists’ knowledge was significantly associated with gender, age, years of experience, and self-awareness regarding DFIs. Male pharmacists, younger professionals, and individuals with more than six years of experience showed higher knowledge scores. This is consistent with previous research that demonstrates that demographic and professional factors, including age, employment status, and practical experience affected the healthcare professionals’ knowledge of DFIs [19,16,21]. Although age was not significantly associated with knowledge scores in the univariate analysis, it became significant in the multivariable regression model after adjustment for other demographic variables. This suggests that potential confounding factors may influence the relationship between age and knowledge scores. However, given the borderline statistical significance, this finding should be interpreted with caution.

Regarding food–drug interactions, participants demonstrated good awareness of DFIs involving central nervous system (CNS) and narrow therapeutic index drugs, such as Diazepam, MAOI, Digoxin, and Warfarin. The attentiveness of the DFIs to such drugs may be attributed to their early discovery, utilization, and extensive research conducted on them [20,22]. Making them recognizable illustrations of DFIs in both literary contexts and educational institutions, as well as practical environments. [22]. Similarly, pharmacists recognized interactions leading to reduced drug absorption through complex formation, deterring absorption and ultimately resulting in lowering drug bioavailability [20,23]. However, knowledge gaps remained for less frequently recognized interactions, such as those between potassium-rich foods and Spironolactone, highlighting areas for targeted educational improvement.

With respect to drug–alcohol interactions, pharmacists showed greater level of awareness compared to some DFI areas, over three-quarters accurately identified potential interactions between alcohol with methotrexate, warfarin, isoniazid, metformin, paracetamol, and antihistamines. The enhanced awareness may be due to the fact that these medicines are well known for their hepatotoxicity, effects on the CNS, or increased risk of bleeding when used in combination with alcohol. However, given the risk of alcohol consumption poses to public health, it is concerning that some individuals did not provide accurate answers to these questions indicating that there is potential for improvement. From a clinical perspective, failure to recognize high-risk interactions—such as potassium-rich foods with spironolactone or alcohol with hepatotoxic medications—may expose patients to serious adverse events including hyperkalaemia, bleeding, or liver injury. These gaps therefore represent meaningful patient safety concerns rather than solely academic deficiencies.

These results are in line with research conducted both internationally and in other Middle Eastern nations, which indicates that pharmacists and other healthcare professionals have moderate to inadequate awareness of DFIs/DAIs [16,19,20,24,25]. Healthcare workers in these studies usually showed a thorough understanding of high-risk or extensively researched interactions, but they showed limited awareness of less frequent or recently identified interactions. This pattern emphasizes the necessity of ongoing professional development and the inclusion of context-specific, clinically relevant DFI/DAI content in pharmacy education.

Implications for practice

The present findings carry important implications for pharmacy practice in the UAE. Pharmacists are often the first point of contact for patients and thus play a critical role in counselling about both food–drug and drug–alcohol interactions. Emphasizing the need for structured training and continuous professional development focused on clinically relevant food–drug interactions. Such programs proved to be imperative and effective in improving healthcare providers’ knowledge and practices [25]. Therefore, incorporating mandatory DFI/DAI training within pharmacy curricula and structured continuing education programs for practicing pharmacists—across both hospital and community settings—would strengthen professional competencies and promote safer medication use.

Study limitations

This study has several limitations. First, self-selection bias may have occurred, as pharmacists who were more motivated or interested in DFIs/DAIs may have been more likely to participate. Second, the reliance on self-reported responses introduces the possibility of social desirability bias, although this was eased by ensuring anonymity, which is known to reduce both social desirability and social anxiety. Third, the study may have been more susceptible to selection and recall biases due to the use of an online survey, which may have influenced the representativeness of the sample. Finally, the results are specific to community pharmacists in the United Arab Emirates and might not apply to hospital pharmacists or other healthcare professionals. Additionally, the knowledge assessment relied on closed-ended, recall-based questions, which may not fully capture applied clinical decision-making or real-world counselling practices. Furthermore, all items were equally weighted despite differences in clinical severity among interactions. Future studies incorporating simulated cases, observational methods, or patient outcomes would provide a more comprehensive evaluation of pharmacists’ competencies.

Future research directions

Future research should examine pharmacists’ knowledge and practices in a variety of healthcare contexts, such as clinical settings and hospitals, to capture more comprehensive picture of pharmacists’ proficiency in handling DFIs and DAIs. Focus groups and interviews are examples of qualitative research methods that may be used to identify the underlying causes of knowledge gaps and barriers to putting knowledge into practice. Intervention studies are also required to assess how well case-based learning programs, focus active training, and continuing education enhance knowledge and counselling abilities. Lastly, investigating patients’ knowledge and awareness of DFIs and DAIs as well as how pharmacists might best assist them will provide important insights into maximizing the safe use of medications in the UAE.

Conclusion

In conclusion, this study emphasizes the necessity of a comprehensive educational approach. Pharmacists in the UAE can be more capable to recognize, advise on, and prevent harmful food-drug and drug-alcohol interactions by combining formal academic training, continuing professional development, and workplace-based reinforcement. This will ultimately strengthen medication safety and improve healthcare outcomes.

Supporting information

S1 Questionnaire. Survey instrument used to assess pharmacists’ knowledge of drug–food and drug–alcohol interactions.

(PDF)

pone.0346144.s001.pdf (180.2KB, pdf)
S1 Data. Anonymized raw dataset underlying the findings of this study.

(XLSX)

pone.0346144.s002.xlsx (75.7KB, xlsx)

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

References

  • 1.Teodoro AJ. Bioactive compounds of food: their role in the prevention and treatment of diseases. In: Oxidative medicine and cellular longevity. 2019. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Deng J, Zhu X, Chen Z, Fan CH, Kwan HS, Wong CH, et al. A review of food-drug interactions on oral drug absorption. Drugs. 2017;77(17):1833–55. doi: 10.1007/s40265-017-0832-z [DOI] [PubMed] [Google Scholar]
  • 3.Genser D. Food and drug interaction: consequences for the nutrition/health status. Ann Nutr Metab. 2008;52 Suppl 1:29–32. doi: 10.1159/000115345 [DOI] [PubMed] [Google Scholar]
  • 4.Won CS, Oberlies NH, Paine MF. Mechanisms underlying food-drug interactions: inhibition of intestinal metabolism and transport. Pharmacol Ther. 2012;136(2):186–201. doi: 10.1016/j.pharmthera.2012.08.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Mallhi TH, Sarriff A, Adnan AS, Khan YH, Qadir MI, Hamzah AA, et al. Effect of fruit/vegetable-drug interactions on CYP450, OATP and p-Glycoprotein: a systematic review. Trop J Pharm Res. 2015;14(10):1927. doi: 10.4314/tjpr.v14i10.27 [DOI] [Google Scholar]
  • 6.HHS CDC. Harmful interactions: mixing alcohol with medicines. 2014. Accessed 2025 June 16. https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/harmful-interactions-mixing-alcohol-with-medicines
  • 7.Joany S, Neves F, Paula De Oliveira A, Alcides Da M, Diniz S, Carrera M, et al. Prevalence and predictors of potential drug-food interactions among the elderly using prescription drugs. J Chem Pharm Res. 2016;8(4):965–72. [Google Scholar]
  • 8.Köse I, Gençyürek G, Altınbaş Atan Z, Elmas BÖ. View of analysis of drug-food interactions in inpatient treatment: a university hospital case. Med Res Arch. 2021;9. doi: 10.18103/mra.v9i2.2345 [DOI] [Google Scholar]
  • 9.Kirby BJ, Unadkat JD. Perspectives commentaries grapefruit juice, a glass full of drug interactions?. Clin Pharmacol Therap. 2007;81. [DOI] [PubMed] [Google Scholar]
  • 10.Dresser GK, Bailey DG, Leake BF, Schwarz UI, Dawson PA, Freeman DJ, et al. Fruit juices inhibit organic anion transporting polypeptide-mediated drug uptake to decrease the oral availability of fexofenadine. Clin Pharmacol Ther. 2002;71(1):11–20. doi: 10.1067/mcp.2002.121152 [DOI] [PubMed] [Google Scholar]
  • 11.Bushra R, Aslam N, Khan AY. Food-drug interactions. Oman Med J. 2011;26(2):77–83. doi: 10.5001/omj.2011.21 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Wajid S, Al-Arifi MN, Al Nomay HA, Al Mousa YN, Babelghaith SD. Knowledge and perception of Community Pharmacists’ towards generic medicines in Saudi Arabia. Biomed Res-India. 2015. www.biomedres.info [Google Scholar]
  • 13.Joint Commission on Accreditation of Health Care Organizations PF. Accreditation manual for hospitals: standards. 1994. https://www.jointcommission.org/standards/
  • 14.Benni JM, Tubaki BR. Knowledge and awareness of food and drug interactions (FDI): a survey among health care professionals. Inter J Pharmacol Clin Sci. 2012;1. [Google Scholar]
  • 15.Al-Arifi MN, Wajid S, Al-Manie NK, Al-Saker FM, Babelgaith SD, Asiri YA, et al. Evaluation of knowledge of Health care professionals on warfarin interactions with drug and herb medicinal in Central Saudi Arabia. Pak J Med Sci. 2016;32(1):229–33. doi: 10.12669/pjms.321.8902 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Zawiah M, Yousef A-M, Khan AH, Al-Ashwal FY, Matar A, ALKhawaldeh B, et al. Food-drug interactions: knowledge among pharmacists in Jordan. PLoS One. 2020;15(6):e0234779. doi: 10.1371/journal.pone.0234779 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Snr WS, Bashatah A, Al-Rawi MBA. Evaluation of knowledge of food–drug and alcohol–drug interactions among undergraduate students at King Saud University – an observational study. J Multidiscip Healthc. 2022;15:2623–33. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Ministry of health and Prevention. United Arab Emirates statistical annual report. Abu Dhabi, United Arab Emirates; 2020. https://mohap.gov.ae/assets/download/eb379300/UAE%20Statistical%20Annual%20Report%202020.docx.aspx [Google Scholar]
  • 19.Radwan A, Sweileh A, Shraim W, Hroub A, Elaraj J, Shraim N. Evaluation of community pharmacists’ knowledge and awareness of food–drug interactions in Palestine. Int J Clin Pharm. 2018;40(3):668–75. [DOI] [PubMed] [Google Scholar]
  • 20.Couris RR, Dallal GE, Blumberg JB, Dwyer JT, Couris RR, Tataronis GR. Assessment of healthcare professionals’ knowledge about warfarin-vitamin K drug-nutrient interactions. J Am Coll Nutr. 2000;19(4):439–45. [DOI] [PubMed] [Google Scholar]
  • 21.Nelson ML, Levy SB. The history of the tetracyclines. Ann N Y Acad Sci. 2011;1241:17–32. doi: 10.1111/j.1749-6632.2011.06354.x [DOI] [PubMed] [Google Scholar]
  • 22.Stargrove MB, Jonathan T, McKee DL. Herb, nutrient, and drug interactions: clinical implications and therapeutic strategies. Mosby Elsevier; 2008. 932. [Google Scholar]
  • 23.Balaban U, Balaban TY, Cakir BK. Assessment of food-drug interaction knowledge among Turkish healthcare professionals. BMC Med Educ. 2025;25(1). [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Khong JHC, Tuan Mahmood TM, Tan SL, Voo JYH, Wong SW. Knowledge, attitude and practice (KAP) on food-drug interaction (FDI) among pharmacists working in government health facilities in Sabah, Malaysia. PLoS One. 2024;19(7):e0304974. doi: 10.1371/journal.pone.0304974 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Bassiouny RME, Ouda MM. The effect of food–drug interactions educational programs on knowledge and practices of nurses working at pediatric outpatient clinics in El-Beheira General Hospitals. IOSR J Nurs Health Sci. 2019;8(4):34–48. Available from: http://www.iosrjournals.org [Google Scholar]

Decision Letter 0

Mohammed Zawiah

6 Feb 2026

Dear Dr. Abumueis,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Mar 23 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

  • A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols ..

We look forward to receiving your revised manuscript.

Kind regards,

Mohammed Zawiah

Academic Editor

PLOS One

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

Before we proceed with your manuscript, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible.

Please update your Data Availability statement in the submission form accordingly.

3. In the online submission form, you indicated that the data underlying this cross-sectional study are available from the corresponding author upon reasonable request. The dataset contains sensitive participant information, and public sharing is restricted to protect confidentiality. Data will be shared in anonymized form with qualified researchers upon reasonable request.

All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information.

This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval.

4. Please remove your figures from within your manuscript file, leaving only the individual TIFF/EPS image files, uploaded separately. These will be automatically included in the reviewers’ PDF.

5. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files.

6. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Partly

Reviewer #4: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

Reviewer #1: This manuscript addresses an important and clinically relevant topic regarding community pharmacists’ knowledge of drug–food and drug–alcohol interactions in the UAE. The study is well designed, clearly written, and fills a regional research gap, as similar data from the UAE are limited. The s questionnaire shows acceptable reliability, and the statistical analyses are appropriate. Results are presented clearly and discussed in relation to previous regional and international studies.

Some points require clarification. The recruitment through online professional groups may have introduced selection bias, which may have influenced knowledge scores and should be discussed in more depth. The associations between knowledge scores and demographic factors (gender, age, experience) should be interpreted cautiously, with emphasis that causality cannot be inferred. Highlighting the clinical significance of specific knowledge gaps would further strengthen the practical implications.

Ethical approval and consent procedures are clearly reported, and no concerns regarding research or publication ethics were identified.

Overall, this is a valuable contribution and is suitable for publication after minor revisions.

Reviewer #2: The study is purely descriptive and confirmatory, documenting “moderate knowledge” among pharmacists—a conclusion that is already well-established in the literature. There is no hypothesis-driven framework, no conceptual model, and no attempt to link knowledge gaps to measurable patient safety outcomes, dispensing errors, or real-world clinical consequences.

Knowledge was assessed using closed-ended, recall-based questions that test memorization of textbook examples rather than applied clinical decision-making. The scoring system treats all items as equally important, despite major differences in clinical risk (e.g., caffeine–diazepam vs. potassium–spironolactone). No weighting, validation against practice behavior, or triangulation with real counselling practices was performed.

Reviewer #3: The study addresses an important issue but inferential statistics have not been utilized properly. comparison between different genders, graduation year, nationality, age, and location need to be added showing the significance of these factors and reflects the curricular impact of pharmacy practice.

Reviewer #4: The manuscript is well written and developed.

The title is appropriate and matches the objectives of the study.

The methodology is robust.

The findings are valuable and well presented.

The conclusion is well stated, reflecting the results section

A minor revision is required: that is paraphrasing line 10-15 in page 9.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy .-->

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

PLoS One. 2026 Mar 27;21(3):e0346144. doi: 10.1371/journal.pone.0346144.r002

Author response to Decision Letter 1

10 Feb 2026

Dear Editor, Dear Reviewers,

We would like to thank the reviewers for their valuable comments and suggestions. We addressed all points and revised the script accordingly. Revisions are marked in YELLOW in the script. We downloaded the revised manuscript and used red highlight for the new comments.

We hope that this revision is satisfactory. Thank you.

Reviewer comments

Reviewer #1:

1-The recruitment through online professional groups may have introduced selection bias, which may have influenced knowledge scores and should be discussed in more depth.

2-The associations between knowledge scores and demographic factors (gender, age, experience) should be interpreted cautiously, with emphasis that causality cannot be inferred.

3-Highlighting the clinical significance of specific knowledge gaps would further strengthen the practical implications.

Reviewer #2:

1-The study is purely descriptive and confirmatory, documenting “moderate knowledge” among pharmacists—a conclusion that is already well-established in the literature.

2-There is no hypothesis-driven framework, no conceptual model, and no attempt to link knowledge gaps to measurable patient safety outcomes, dispensing errors, or real-world clinical consequences.

3-Knowledge was assessed using closed-ended, recall-based questions that test memorization of textbook examples rather than applied clinical decision-making.

4-The scoring system treats all items as equally important, despite major differences in clinical risk (e.g., caffeine–diazepam vs. potassium–spironolactone). No weighting, validation against practice behavior, or triangulation with real counselling practices was performed.

Reviewer #3:

The study addresses an important issue but inferential statistics have not been utilized properly. comparison between different genders, graduation year, nationality, age, and location need to be added showing the significance of these factors and reflects the curricular impact of pharmacy practice.

Reviewer #4:

1-A minor revision is required: that is paraphrasing line 10-15 in page 9.

Authors’ response:

Reviewer #1: Thank you very much for your comments.

1-To address the selection bias, we added “This convenience-based online recruitment approach may have preferentially attracted pharmacists who are more professionally engaged or academically inclined, potentially introducing selection bias.” In the method section.

2-knowledge was influenced by gender in in the discussion changed to read as “were significantly associated with” to avoid causal is this correct.

3-paragraph read as “From a clinical perspective, failure to recognize high-risk interactions—such as potassium-rich foods with spironolactone or alcohol with hepatotoxic medications—may expose patients to serious adverse events including hyperkalaemia, bleeding, or liver injury. These gaps therefore represent meaningful patient safety concerns rather than solely academic deficiencies.” Added to the discussion

Reviewer #2: Thank you very much for your comments.

1-We added “Although the study design was cross-sectional and descriptive in nature, it provides essential baseline data regarding pharmacists’ knowledge in a region where such evidence has been lacking. Establishing this baseline is a necessary first step for designing targeted educational and interventional strategies aimed at improving patient safety.” To the first paragraph in the discussion to address the comment.

2-Thank you very much for your comments we added “Guided by the premise that pharmacists’ demographic and professional characteristics may influence their knowledge and counselling practices, we hypothesized that knowledge levels would vary according to age, gender, and years of experience. Identifying these variations may help inform targeted educational strategies and professional development initiatives to enhance medication safety.” In the introduction to address the hypothesis/ framework comment.

3-paragraph read as “The questionnaire primarily assessed factual knowledge using closed-ended items to ensure standardization and objective scoring across respondents. While this approach allows efficient evaluation of baseline knowledge, it may not fully reflect real-world counselling behaviors or clinical decision-making.” added to the method section.

Also, we added “Additionally, the knowledge assessment relied on closed-ended, recall-based questions, which may not fully capture applied clinical decision-making or real-world counselling practices.” To the limitation section

4-Paragraph added to method section read as “All items were weighted equally to maintain consistency and comparability with previous knowledge-based surveys. However, we acknowledge that different interactions may carry varying levels of clinical risk, and future research could consider risk-based weighting or case-based assessment approaches.”

Also, we added “Furthermore, all items were equally weighted despite differences in clinical severity among interactions. Future studies incorporating simulated cases, observational methods, or patient outcomes would provide a more comprehensive evaluation of pharmacists’ competencies.” To the limitation section.

Reviewer #3: Thank you very much for your comments.

Independent-samples t-tests were conducted and paragraph read as

“Independent-samples t-tests were conducted to compare mean knowledge scores across binary demographic and professional variables, including gender, age group, geographical location, pharmacy type, and years of experience. “Added to the method section

Also, the results presented in the result section “Univariate analysis using independent-samples t-tests identified several demographic factors associated with knowledge scores. Males demonstrated significantly higher total knowledge scores than females (22.54 ± 7.27 vs. 16.60 ± 6.40; mean difference = 5.94; p < 0.001). Pharmacists residing in Abu Dhabi also had higher scores compared with those from other emirates (20.57 ± 7.16 vs. 16.77 ± 7.20; mean difference = 3.90; p = 0.038). Similarly, pharmacists with ≥6 years of experience showed higher knowledge scores than those with ≤5 years of experience (20.67 ± 7.79 vs. 18.57 ± 7.16; mean difference = 2.10; p = 0.001).

No significant differences were observed by age group (19.66 ± 7.15 vs. 18.77 ± 7.57; mean difference = 0.89; p = 0.232) or practice setting (19.63 ± 7.48 vs. 18.28 ± 7.16; mean difference = 1.35; p = 0.164).”

Reviewer #4: Thank you very much for your comments.

The specified section has been paraphrased for clarity to read as “highlighting the imperative role of training pharmacists and the incorporation of educational curricula and continuous educational programs for clinically relevant food-drug interactions.”

Journal requirements

1. PLOS formatting style

All manuscript formatting has been revised to comply with PLOS ONE style guidelines.

2–3. Data sharing policy and Data Availability statement

As there are no ethical or legal restrictions preventing data sharing, we prepared and uploaded an anonymized raw dataset.

• Uploaded dataset as Supporting Information (S1 Data.xlsx)

• Uploaded the full questionnaire as Supporting Information (S1 Questionnaire.pdf)

• Updated the Data Availability statement in the manuscript to:

All relevant data underlying the findings of this study are provided within the manuscript and its Supporting Information files.

4. Figures

All figures have been:

• Removed from the main manuscript

• Saved individually in TIFF format

• Uploaded separately as Fig1–Fig6 according to PLOS naming requirements

5. Tables

All tables:

• Included directly within the manuscript

• Presented as editable Word tables

• Positioned immediately after first citation

• Not uploaded as separate files

Decision Letter 1

Mohammed Zawiah

10 Mar 2026

Dear Dr. Abumueis,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

ACADEMIC EDITOR:-->-->

Thank you for the revision. The manuscript has improved. Please address the new comment from Reviewer 2. In addition, two important points still need revision from my side:

  • Please clarify the age-related findings. In univariate analysis, age was not significant (p = 0.232), but in multiple regression age 20–29 years became significant (p = 0.041). That can happen after adjustment, but the manuscript does not explain it. Since this is a borderline result, it needs cautious interpretation.

  • Please strengthen the limitation on sampling bias. The manuscript acknowledges possible selection bias from online recruitment, but this is later minimized. Please keep the limitation wording balanced and transparent.

Please submit your revised manuscript by Apr 24 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

  • A letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols ..

We look forward to receiving your revised manuscript.

Kind regards,

Mohammed Zawiah

Academic Editor

PLOS One

Journal Requirements:

1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Partly

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: I Don't Know

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: No

Reviewer #3: Yes

**********

Reviewer #2: - Alcohol use prevalence is required to be added in the introduction.

- All comment have been addressed.

- English proofreading is required.

Reviewer #3: I recommend therticle to be Accepted as it is since The author added all of the required corrections.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy .-->

Reviewer #2: No

Reviewer #3: Yes: Muaed Jamal AlomarMuaed Jamal Alomar

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

PLoS One. 2026 Mar 27;21(3):e0346144. doi: 10.1371/journal.pone.0346144.r004

Author response to Decision Letter 2

12 Mar 2026

Dear Academic Editor and Reviewers,

We would like to thank the Academic Editor and reviewers for their valuable comments and suggestions. We addressed all points and revised the script accordingly. All changes are highlighted in the tracked-changes version of the manuscript. Our point-by-point responses are provided below.

We hope that this revision is satisfactory. Thank you.

Academic Editor Comments

1. Please clarify the age-related findings. In univariate analysis, age was not significant (p = 0.232), but in multiple regression age 20–29 years became significant (p = 0.041). That can happen after adjustment, but the manuscript does not explain it. Since this is a borderline result, it needs cautious interpretation.

2. Please strengthen the limitation on sampling bias. The manuscript acknowledges possible selection bias from online recruitment, but this is later minimized. Please keep the limitation wording balanced and transparent.

Reviewer #2:

1. Alcohol use prevalence is required to be added in the introduction.

2. English proofreading is required.

Authors’ response:

Academic Editor: Thank you very much for your comments.

1. We have clarified this point in the Discussion section and added an explanation that the association became significant after adjustment for other variables in the multivariable regression model. We added new sentences to the discussion read as “Although age was not significantly associated with knowledge scores in the univariate analysis, it became significant in the multivariable regression model after adjustment for other demographic variables. This suggests that potential confounding factors may influence the relationship between age and knowledge scores. However, given the borderline statistical significance, this finding should be interpreted with caution.”

2. We have revised the limitations section to present the potential sampling bias more transparently. The sentence: “however, as pharmacists are increasingly using smartphones and the internet in their work, this is unlikely to have had an impact on our findings.” Deleted and replaced with: “Third, the study may have been more susceptible to selection and recall biases due to the use of an online survey, which may have influenced the representativeness of the sample.”

Reviewer #2: Thank you very much for your comments.

1-“Although alcohol consumption in the United Arab Emirates is regulated, evidence indicates that alcohol use remains present and represents a public health concern in the country [7], underscoring the importance of awareness of potential drug–alcohol interactions in clinical practice.” Added to the introduction to address the comment.

2- Proofreading is done. Examples are below:

Introduction

• Current

For example, Interactions between alcohol and antihistamines, as well as nonsteroidal anti-inflammatory medicines (NSAIDs), elevate the risk of internal bleeding, and respiratory difficulties. or cause life-threatening cardiovascular complications when taken with monoamine oxidase inhibitors (MAOIs).

Replaced with:

For example, interactions between alcohol and antihistamines or nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk of internal bleeding and respiratory complications. Alcohol may also cause life-threatening cardiovascular complications when combined with monoamine oxidase inhibitors (MAOIs).

• Current

medication review [13]According to international guidelines

Space added

medication review [13]. According to international guidelines

• Current

While excessive intake of vitamin K–rich foods diminish warfarin's safety and effectiveness

Replaced with

Excessive intake of vitamin K–rich foods diminishes warfarin's safety and effectiveness

Results

• Current

"Does protein-rich foods affect the efficacy of Levodopa?"

Replaced with

"Do protein-rich foods affect the efficacy of levodopa?"

Discussion

• Current

The results of this study revealed that pharmacists in the UAE have overall moderate knowledge among UAE pharmacists.

Replaced with:

The results of this study indicate that community pharmacists in the UAE have an overall moderate level of knowledge.

• Current

This is consistent with previous research that demonstrate

Replaced with:

This is consistent with previous research that demonstrates

• Current

UAE regarding drug interactions

To read better:

UAE regarding drug–food and drug–alcohol interactions

Limitations

• Current

second, the reliance on self-reported responses

Replaced with:

Second, the reliance on self-reported responses

Future research

• Current

lastly, investigating patients' knowledge

Replaced with:

Lastly, investigating patients' knowledge

Attachment

Submitted filename: Response to Reviewers.docx

pone.0346144.s005.docx (34KB, docx)

Decision Letter 2

Mohammed Zawiah

16 Mar 2026

Drug–food and drug–alcohol interactions: pharmacists’ knowledge gaps and patient safety concerns in the United Arab Emirates

PONE-D-25-61208R2

Dear Dr. Abumueis,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact  and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support ..

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Mohammed Zawiah

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Acceptance letter

Mohammed Zawiah

PONE-D-25-61208R2

PLOS One

Dear Dr. Abumueis,

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team.

At this stage, our production department will prepare your paper for publication. This includes ensuring the following:

* All references, tables, and figures are properly cited

* All relevant supporting information is included in the manuscript submission,

* There are no issues that prevent the paper from being properly typeset

You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps.

Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing.

If we can help with anything else, please email us at customercare@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Mohammed Zawiah

Academic Editor

PLOS One

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Questionnaire. Survey instrument used to assess pharmacists’ knowledge of drug–food and drug–alcohol interactions.

    (PDF)

    pone.0346144.s001.pdf (180.2KB, pdf)
    S1 Data. Anonymized raw dataset underlying the findings of this study.

    (XLSX)

    pone.0346144.s002.xlsx (75.7KB, xlsx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    pone.0346144.s005.docx (34KB, docx)

    Data Availability Statement

    All relevant data are within the paper and its Supporting Information files.

    Articles from PLOS One are provided here courtesy of PLOS

    RESOURCES