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

Taima Qudah; Leen Fino; Razan I. Nassar; Suhad Abumueis

doi:10.1371/journal.pone.0346144

Peer Review History

Original SubmissionNovember 22, 2025
6 Feb 2026 Decision Letter - Mohammed Zawiah, Editor 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. 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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? 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Revision 1
10 Feb 2026 Author Response 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 https://doi.org/10.1371/journal.pone.0346144.r002
10 Mar 2026 Decision Letter - Mohammed Zawiah, Editor 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. https://doi.org/10.1371/journal.pone.0346144.r003
Revision 2
12 Mar 2026 Author Response 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 Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0346144.r004
16 Mar 2026 Decision Letter - Mohammed Zawiah, Editor 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: https://doi.org/10.1371/journal.pone.0346144.r005
Formally Accepted
Acceptance Letter - Mohammed Zawiah, Editor 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 https://doi.org/10.1371/journal.pone.0346144.r006

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