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Published in the Bulletin of Experimental Treatments for AIDS Spring 2002 issue, by the San Francisco AIDS Foundation.
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Managing Nausea, Vomiting, and Diarrhea Liz Highleyman
Most people with HIV/AIDS experience nausea and diarrhea at some point during the course of their illness. Roughly one-third of people infected with HIV develop acute retroviral syndrome (ARS), a flu-like illness, one to three weeks following exposure to the virus; nausea and diarrhea are among the symptoms associated with ARS. At later stages of HIV disease, once the immune system is compromised and CD4 cell counts fall below 200 cells/mm3, people are susceptible to a range of opportunistic illnesses (OIs), several of which can cause nausea and diarrhea. Today, however, as improved combination antiretroviral treatment has reduced the incidence of OIs, adverse reaction to drugs is the most common cause of nausea, vomiting, and diarrhea in people with HIV/AIDS. Of all the symptoms of HIV disease and the side effects of the drugs used to treat it, nausea, vomiting, and diarrhea are among the most distressing. Not only do they limit daily activities and have a detrimental effect on quality of life, they can also compromise an individual's health by interfering with nutrition and medication regimens. Often, nausea and vomiting are signs that the stomach is irritated and trying to rid itself of something it finds disagreeable. This may be caused, for example, by excessive alcohol consumption, overeating, or consumption of contaminated food or water. Many different pathogens (infectious micro-organisms) attack the GI tract and can cause nausea and vomiting (see "Pathogens that Cause Nausea, Vomiting, and Diarrhea," below). In other cases, nausea is less directly related to the stomach itself; for example, in some people nausea accompanies migraine headaches, and women often experience nausea (morning sickness) during the first trimester of pregnancy due to hormonal changes. Other possible causes of nausea and vomiting include head injury or brain damage (affecting the brain's vomiting center), inner ear disorders, intestinal obstructions, liver disease (e.g., hepatitis, cirrhosis), pancreas dysfunction, myocardial infarction (heart attack) or congestive heart failure, endocrine disorders (e.g., diabetes), motion sickness, and emotional stress. In people with HIV/AIDS, nausea and vomiting are common side effect of many of the drugs used to treat HIV and associated conditions (see "Nausea, Vomiting, and Diarrhea as Drug Side Effects," below).
Nausea and vomiting are often transient and resolve on their own. However,
severe or persistent vomiting can cause dehydration, electrolyte loss,
malnutrition, and weight loss (see "Dangers of Vomiting and Diarrhea,"
below). Also, with prolonged vomiting the stomach acid in the vomitus
can irritate the tissues of the esophagus and cause tooth damage. People
should consult a health-care provider if they experience the following
symptoms:
In order to treat nausea and vomiting, the underlying causes must be
determined; however, measures to relieve symptoms may begin before the
cause is known. Health-care providers typically will ask about the severity,
frequency, timing (e.g., after meals or when the stomach is empty),
and duration of nausea and vomiting, as well as what medications patients
are taking and whether they are experiencing additional symptoms. Diarrhea is one of the most common complaints of people with HIV/AIDS, occurring in at least 50% of cases. It is more common in people with advanced HIV disease. Diarrhea typically is defined as two or more loose stools per day. However, what can be considered diarrhea depends on a person's usual bowel habits; some people normally have more frequent or more loose stools than others. Enteritis is inflammation of the small intestine; gastroenteritis refers to inflammation of both the stomach and the small intestine. Colitis is inflammation of the large intestine (colon). Normally when food is digested, nutrients are absorbed in the small intestine and water is absorbed in the colon, leaving a well-formed stool. Diarrhea occurs when water absorption is disrupted, when too much fluid is secreted into the intestines, or when digested food moves too quickly through the colon to allow proper extraction of water. Diarrhea may be due to problems in the small or large intestine. Small intestine diarrhea is typically higher volume (about two liters per day), while large intestine diarrhea is generally lower volume (about one-half liter per day). Diarrhea may be caused by microorganisms (see "Pathogens that Cause Nausea, Vomiting, and Diarrhea," below), food intolerances or allergies, chronic bowel disorders (including inflammatory bowel disease, Crohn's disease, irritable bowel syndrome, ulcerative colitis, and celiac disease), and emotional stress. Many people experience diarrhea, cramps, and intestinal gas as a result of lactose intolerance, caused by the lack of an enzyme (lactase) required to digest lactose, a sugar found in milk; the condition is more common in people of African and Asian descent. Diarrhea also sometimes occurs when a person takes antibiotics that kill off normal intestinal bacteria. People with HIV/AIDS may have diarrhea related to any of these causes. In addition, diarrhea is a frequent side effect of antiretroviral drugs (see "Nausea, Vomiting, and Diarrhea as Drug Side Effects," below) and people with advanced HIV disease may have OIs that cause diarrhea. In some people with HIV/AIDS, diarrhea has no obvious specific cause and is attributed to HIV enteropathy, or intestinal disease caused by the virus itself (possibly related to HIV infection of intestinal lymphatic tissues or damage to the microvilli lining the intestines).
Improper digestion and absorption of fats also can cause diarrhea. A
study by Michael A. Poles, MD, of the University of California at Los
Angeles (UCLA) Medical Center and colleagues found evidence of fat malabsorption
in 30 of 33 HIV positive persons with diarrhea evaluated between 1995
and 1999; the rates of malabsorption were similar in people receiving
combination regimens containing a protease inhibitor (PI) and those
taking only nucleoside reverse transcriptase inhibitors (NRTIs). According
to Dr. Poles, "Fat malabsorption is probably a significant cause
of diarrhea in these patients, certainly worthy of an attempt at diagnosis
and treatment." Often fat malabsorption is associated with pancreatic
disease (the pancreas is a digestive organ that produces enzymes that
help digest fats). However, the researchers did not find evidence of
pancreatic disease in their study participants, and Dr. Pole suggested
that antiretroviral drugs may have had a detrimental effect on fat absorption.
Like nausea, diarrhea is a symptom, and the underlying cause (or, often, causes) must be determined in order to treat it appropriately. Physicians typically will ask patients about possible exposure to pathogens, frequency and length of diarrhea, normal bowel habits, and additional symptoms. Often a stool sample is taken to determine what type of microorganism or parasite, if any, is responsible. Blood or urine laboratory tests also may be conducted (sometimes microorganisms can be detected in the blood but not the stool).
As with nausea, x-ray tests may be done, although in this case barium
is administered as an enema (by rectum) rather than swallowed. Endoscopic
tests may be conducted in order to view the interior of the intestines;
a colonoscopy is a procedure for viewing the entire large intestine
by means of a lighted instrument inserted through the anus, while a
sigmoidoscopy examines just the lower part of the colon. Physicians
may take a biopsy sample of the intestinal lining to examine for pathogens,
cell abnormalities, or tissue damage. Common GI Pathogens A wide variety of microorganisms-bacteria, parasites, viruses, and fungi-can cause nausea, vomiting, and diarrhea (see sidebar on page 32). These range from common bacteria and parasites that often cause food poisoning and traveler's diarrhea in the population at large, to opportunistic pathogens that typically cause disease only in people with compromised immune systems. Food poisoning, which can lead to both vomiting and diarrhea, is caused by food or water contaminated with microorganisms or toxins. Most pathogens that cause diarrhea are transmitted by the fecal-oral route (from feces to mouth), often due to improper hygiene when handling food. Traveler's diarrhea is a common name for food poisoning contracted while traveling, especially in developing countries with poor sanitation systems. (See sidebar on page 33 for tips on preventing GI infections.) While food poisoning and traveler's diarrhea are common in the general population, people with HIV/AIDS who have weakened immune systems are more likely to become ill due to food- and water-borne pathogens and also are more likely to develop bacteremia or septicemia (bacteria and/or bacterial toxins in the bloodstream). Although vomiting and diarrhea due to infection often clear up spontaneously within a few days, they may be more persistent and require treatment, especially in immunocompromised people.
The most common bacterial food poisoning culprits are Salmonella species
(one of which, S. typhi, causes typhoid fever), Shigella species, Campylobacter
jejuni, and Escherichia coli (especially the O157:H7 strain). People
with bacterial GI infections typically have abdominal pain and watery
diarrhea. Dysentery is a more severe form of infectious diarrhea associated
with bloody or pus-filled discharge and usually accompanied by fever.
Bacterial GI infections are treated with a variety of antibiotics; if
the specific cause is unknown, some physicians treat presumptively with
a wide-spectrum drug such as ciprofloxacin (Cipro) or TMP-SMX (Bactrim,
Septra).
Two common protozoan parasites transmitted by contaminated food and
water are Giardia lamblia and Entamoeba histolytica (the cause of amoebic
dysentery). Giardia lives in animals as well as humans, and may be present
in streams and rivers far from human habitation. Both Giardia and amoebas
can be transmitted through oral/anal sex or other contact with feces
during sexual activity. Unlike many bacterial GI infections, Giardia
can last for months or longer, even in people with healthy immune systems.
The usual treatment for giardiasis is metronidazole; this drug should
not be taken with alcohol, including medications such as liquid ritonavir
(Norvir) that contain alcohol. Amoebas usually are treated with paromomycin
(Humatin) and/or iodoquinol (Yodoquinol). Opportunistic Pathogens
People with late-stage HIV disease and compromised immune systems are
susceptible to several opportunistic pathogens that can cause diarrhea,
including Mycobacterium avium complex (MAC), Cryptosporidium parvum,
and cytomegalovirus (CMV). In fact, these OIs are responsible for some
of the classic symptoms of AIDS (e.g., night sweats, severe wasting)
frequently seen in the early years of the epidemic. These illnesses
typically occur when a person's CD4 cell count falls below 100 cells/mm3.
The incidence of AIDS-related OIs has fallen dramatically with the widespread
use of effective combination antiretroviral therapy. Often if people's
CD4 cell counts rise above 200 cells/mm3 with antiretroviral therapy,
their immune systems are again able to control the pathogens. Cryptosporidiosis, which is transmitted through contaminated food and water (including tap water in some cities), is characterized by abdominal cramps, diarrhea, and wasting. People with fewer than 200 CD4 cells/mm3 may experience prolonged infection. Cryptosporidiosis cannot be cured, but may be treated with paromomycin and/or azithromycin; despite promising studies, in 1998 the U.S. Food and Drug Administration (FDA) declined to approve the experimental drug nitazoxanide (Cryptaz) for this indication. C. cayetanensis and I. belli are treated with TMP-SMX or ciprofloxacin, and maintenance therapy may be needed. A variety of different medications may be used to treat microsporidiosis (including E. bieneusi and E. intestinalis), including albendazole (Albenza), atovaquone (Mepron), fluconazole (Diflucan), metronidazole, pyrimethamine (Daraprim), and TMP-SMX.
CMV is best known as a virus that attacks the eyes, leading to retinitis
(inflammation of the retina) and blindness. However, it also can affect
the GI tract, causing esophagitis (inflammation of the esophagus) and
colitis. CMV colitis is characterized by ulceration of the lining of
the colon. Symptoms may include anorexia (loss of appetite), fever,
and abdominal cramps in addition to diarrhea. Although CMV infection
is very common, the virus usually only causes symptomatic illness in
people with fewer than 50 CD4 cells/mm3. CMV colitis may be treated
with intravenous cidofovir (Vistide), foscarnet (Foscavir), or ganciclovir
(Cytovene); in March 2001 an oral drug called valganciclovir (Valcyte)
was approved (see "Valganciclovir" on pages 19-21 of the Winter
2002 issue of BETA). Nausea, vomiting, and diarrhea are the most common GI toxicities, or side effects, associated with antiretroviral medications. Others include esophagitis, acid reflux ("heartburn"), intestinal gas (flatulence), abdominal cramps, abdominal bloating, and constipation. Although anti-HIV drugs may directly irritate the lining of the GI tract, studies suggest that the drugs actually cause nausea, vomiting, and diarrhea because the body regards them as toxins and tries to eliminate them. In addition, some antiretroviral drugs increase intestinal transit time, causing food to pass more quickly through the intestines and not allowing sufficient time for water to be absorbed by the colon. The occurrence of nausea and diarrhea as drug side effects varies widely among individuals. Some people experience these symptoms frequently, while others experience them rarely or never. Severity also varies widely. People with late-stage HIV disease are prone to more severe symptoms, but people at any stage of disease may experience nausea and diarrhea as a side effect of medications.
Drug side effects can have a major detrimental effect on quality of
life and on medication adherence. Andrea Tramarin, MD, from the Civil
Hospital of Vicenza, Italy, and colleagues reported at the 11th European
Congress of Clinical Microbiology and Infectious Diseases in April 2000
that among people with HIV receiving antiretroviral treatment, those
who experienced severe or moderate diarrhea reported a significantly
impaired quality of life compared with those without diarrhea. A 1998
study by researchers at the University of California at San Francisco
(UCSF) Center for AIDS Prevention Studies found that concern about side
effects was a major factor deterring people from starting antiretroviral
treatment. Nausea, vomiting, and diarrhea also can discourage people
from taking their drugs once they have started. This is especially true
for people with early-stage HIV disease who felt healthy and experienced
few or no symptoms before starting therapy; not surprisingly, some of
these people may come to believe that they are better off without the
drugs. Ultimately, each person with HIV must weigh the benefits and risks of treatment for himself or herself. For many, the benefits of controlling the virus will outweigh negative drug side effects. Others-especially those with early-stage HIV infection who have few or no symptoms-may decide that remaining free from persistent GI distress is more important to them. All currently approved NRTIs, non-nucleoside reverse transcriptase inhibitors (NNRTIs), and PIs are known to cause nausea, vomiting, or stomach upset, and all PIs are known to cause diarrhea. However, certain drugs are associated more often with specific symptoms. For example, among PIs, nelfinavir (Viracept) and Kaletra (lopinavir/ritonavir) most often cause diarrhea, although the diarrhea associated with full-dose ritonavir tends to be more severe. Among the NRTIs, ddI (Videx) has been most associated with diarrhea, although GI side effects are less of a problem with the new enteric-coated formulation (Videx EC). As noted previously, GI symptoms related to antiretroviral therapy typically decrease over time.
Severe nausea and diarrhea are among the symptoms of the potentially
fatal hypersensitivity reaction that occurs in 3-5% of people taking
abacavir (Ziagen) or Trizivir (AZT/3TC/abacavir). Persons who experience
these symptoms (or fever, abdominal pain, sore throat, shortness of
breath, or skin rash) should seek immediate medical care. Vomiting and diarrhea are not only unpleasant and restrictive of daily activities, but also can interfere with the proper absorption of water, food, and medications, potentially leading to dehydration, disruptions in body chemistry, malnutrition, weight loss, and inadequate drug levels.
Dehydration, or an inadequate amount of water in the body, is one of
the most serious potential consequences of vomiting and diarrhea because
it can lead to shock and even death within a short period of time. People
can go without water for only a few days, and even less if the body's
fluids are actively being lost; people with severe diarrhea may lose
as much as a gallon of water in a day. Dehydration can be especially
dangerous in the elderly and in children; in fact, dehydration related
to diarrhea is one of the most common causes of death for children in
the developing world. The symptoms of dehydration include:
Along with water, people with vomiting or diarrhea also lose electrolytes
(minerals), especially sodium, potassium, magnesium, and chloride. Electrolytes
are crucial for many bodily functions, and electrolyte imbalances can
be life-threatening. For example, loss of chloride due to prolonged
vomiting can lead to a condition called metabolic alkalosis, characterized
by mental confusion and muscle spasms.
Diarrhea that continues over a prolonged period of time can cause poor
absorption of nutrients, leading to weight loss. Wasting, or involuntary
loss of more than 10% of baseline body weight, occurs most often in
late-stage HIV disease. Various dietary measures (e.g., commercial formulas
such as Advera or Ensure) and medications (e.g., human growth hormone
[Serostim], megestrol acetate [Megace], anabolic steroids) can help
control wasting. In more severe cases, tube feeding (enteral nutrition)
or intravenous feeding (parenteral nutrition) may be required. People
who experience weight loss due to diarrhea should consult their health-care
providers. A number of different measures may be taken to reduce nausea, vomiting, and diarrhea. If these are caused by a pathogen, treating the underlying infection usually takes care of the symptoms. Other measures provide symptomatic relief, including dietary changes, over-the-counter (OTC) and prescription medications, and various alternative therapies. However, vomiting and diarrhea are natural mechanisms for eliminating harmful microorganisms and toxins from the body. If a pathogen is suspected, most experts recommend that symptomatic treatment should not be started immediately, but rather that vomiting or diarrhea should be allowed to run its course for a few days in an effort to rid the body of the infection. If vomiting and diarrhea are drug side effects, on the other hand, physicians may recommend symptomatic treatment as soon as possible to help the medication stay in the body for a longer period.
Practical and Dietary Measures Often dietary changes alone can relieve nausea, vomiting, and diarrhea. Several of these are effective for multiple GI symptoms (see sidebar on this page). Even when ill, it is important to continue drinking clear liquids in order to avoid dehydration and electrolyte imbalances. As noted above, fruit juices, broth, energy drinks, and herbal teas are good sources of fluids. As symptoms subside, foods should be slowly reintroduced, beginning with simple, bland foods that do not irritate the stomach and intestines. A commonly recommended regimen is the BRAT diet, consisting of bananas, rice (white, not brown), applesauce, and toast (white bread, not whole grain). Experts often recommend eating small, frequent meals or snacks rather than 2-3 large daily meals. Studies indicate that lactose intolerance is common in people with HIV/AIDS. People with lactose intolerance should avoid dairy products; some medications also contain lactose. Lactase replacement products (e.g., Lactaid) may be helpful. Some people find yogurt with live cultures easier to digest than milk. Dietitians often recommend that people with nausea or diarrhea try cutting dairy products out of their diet to see if their symptoms improve. Foods with a high fat content are difficult to digest, and people experiencing nausea or diarrhea should avoid fatty or greasy foods (e.g., sausage, donuts, French fries, nuts, avocados), and minimize their use of margarine, butter, mayonnaise, oils, and dressings. Caffeine, sorbitol (found in some diet and sugar-free products), artificial fats (Olean, Olestra), magnesium-containing antacids, and high-dose vitamin C trigger diarrhea in some people. Foods that are high in soluble fiber (see sidebar on this page) can reduce diarrhea by absorbing excess water in the digestive tract. Psyllium-based bulking agents (e.g., Metamucil, Citrucel) work in a similar manner. Soluble fiber appears especially effective in controlling drug-related diarrhea. Because soluble fiber may affect drug absorption, some experts recommend that it should not be consumed within an hour of taking medications. In contrast, foods high in insoluble fiber or "roughage" (see sidebar on this page) are passed along more rapidly by the intestines and can worsen diarrhea; foods commonly recommended to relieve constipation (e.g., prunes, figs) should not be eaten by people with diarrhea.
People with abdominal cramps should avoid foods and beverages that produce
intestinal gas, including beans, broccoli, cabbage, cauliflower, and
carbonated beverages. People use a variety of measures to avoid bouts of nausea (see sidebar on page 37). For nausea in the morning, some people find it helpful to keep dry crackers by the side of the bed and to eat a few immediately upon waking, before slowly getting out of bed. Some practical measures may be effective for some people and not others, so it is important to experiment and see what works. Strong odors (e.g., ripe cheese, tobacco smoke, perfume) are known to trigger nausea in many people, and should be avoided. If possible, avoid being around cooking odors; using a microwave oven can help keep odors to a minimum. If there is a pattern to nausea (e.g., it occurs one hour after taking a specific drug), try to eat more at times when nausea is minimal. Some dietitians recommend not eating favorite foods during periods of nausea, as this can produce an ongoing aversion to those foods. OTC and Prescription Medications A variety of different OTC (nonprescription) and prescription drugs are used to treat nausea, vomiting, and diarrhea. Because many medications have the potential to interact with antiretroviral and anti-OI drugs, people with HIV should report persistent GI symptoms to their physicians and not attempt to treat them on their own; in addition, physicians should be made aware of all drugs-including nonprescription medications-that their patients are taking. Drugs for Nausea and Vomiting Drugs used to prevent and relieve nausea and vomiting are known as antiemetics. These drugs work by different mechanisms. OTC antinausea medications include bismuth subsalicylate (Pepto-Bismol), dimenhydrinate (Dramamine, marketed for motion sickness), and meclizine (Bonine). Histamine blockers such as cimetidine (Tagamet) and ranitidine (Zantac) work by inhibiting a chemical that stimulates gastric secretion.
Prescription antiemetics affect brain mechanisms that control vomiting.
Among these are drugs that block the action of the neurotransmitters
dopamine, acetylcholine, and serotonin. Drugs used as antiemetics include
prochlorperazine (Compazine), ondansetron (Zofran), dolasetron (Anzemat),
domperidone (Motilium), granisetron (Kytril), lorazepam (Ativan), metoclopramide
(Maxolon, Reglan), promethazine (Phenergan), and tropisetron (Navoban).
Some of these drugs cause their own side effects including drowsiness,
dry mouth, and tardive dyskinesia (involuntary muscle movement). Antidiarrhea Drugs A variety of drugs are used to control diarrhea. Mild diarrhea often can be treated with OTC medications including bismuth subsalicylate, certain antacids, and the clay-like agents attapulgite (e.g., Diatrol, Kaopectate) and kaolin/pectin (e.g., Donnagel, Kapectalin). Many antidiarrhea drugs are antimotility agents that slow the movement of food through the intestines. The most commonly used drug in this class is loperamide, available both as a low-dose OTC medication (Imodium AD, others) and as a stronger prescription formulation. Other prescription antidiarrhea drugs include difenoxin/atropine (Motofen), diphenoxylate/atropine (Lomotil), and octreotide (Sandostatin). For severe, chronic diarrhea, narcotic drugs may be used, including paregoric (tincture of opium), codeine, hydrocodone (Vicodin), methadone, and morphine sulfate; narcotics decrease motility by reducing intestinal muscle contractions (peristalsis). Some antidiarrhea drugs may cause side effects including constipation.
Pancrelipase (Ultrase), a synthetic pancreatic enzyme, helps digest
fats and is used for diarrhea due to fat malabsorption. Studies have
shown that it is effective in treating HIV-associated diarrhea. Cholestyramine
(Questran), a medication that binds bile acids, also appears effective
for certain types of diarrhea; cholestyramine may decrease blood levels
of other medications and should be taken at a different time. Alternative Therapies Several alternative and complementary therapies may be used to manage nausea, vomiting, and diarrhea. These include herbal remedies, nutritional supplements, and Chinese medicine. Herbal Remedies For nausea and diarrhea, herbalists often recommend chamomile, peppermint, or catmint (catnip) tea, which relieve GI spasms. Ginger is used as an antiemetic in many herbal traditions. Ginger root can be eaten raw or steeped to make a tea; candied ginger and ginger ale also may be effective. Other herbs used to relieve nausea include anise, caraway, cinnamon, clove, cumin, goldenseal, nutmeg, and raspberry leaf. Other herbs used for diarrhea include agrimony, bayberry root, black walnut, blackberry root, blueberry leaf and fruit (without the seeds), goldenseal, linden, meadowsweet, nutmeg, raspberry leaf, and slippery elm bark. In addition, several Chinese herbal formulas are available for both nausea and diarrhea. Some herbs can interact with antiretroviral medications; people should consult their physicians before taking herbal remedies. One of the most effective herbal remedies for nausea is cannabis, or marijuana. While currently illegal under federal law, several U.S. states now permit the medicinal use of marijuana. Although few recent controlled clinical trials have been permitted by the federal government, medical cannabis is widely reported to control nausea and vomiting due to cancer chemotherapy and antiretroviral drugs; it is also used to relieve pain and stimulate the appetite. A pharmaceutical formulation of tetrahydrocannabinol (THC, an active component of marijuana) called dronabinol (Marinol) is also available. In several early studies dronabinol was found to have an effectiveness similar to that of prochlorperazine in relieving nausea. Some people find that smoked marijuana does not make them as drowsy or "high" as dronabinol, probably because smoked marijuana works more quickly and people can use only as much as they need to relieve their symptoms. However, smoking is harmful to the lungs, and medical marijuana patients and providers are experimenting with alternative delivery systems. Shaman Botanicals Normal Stool Formula (SB-NSF) is a relatively new antidiarrhea product that contains SP-303, an extract of the Amazonian Croton lechleri tree, which traditionally is used as a GI remedy by South American healers. Rather than decreasing intestinal motility, SP-303 appears to work by reducing the secretion of fluid into the intestines. Originally Shaman Pharmaceuticals attempted to develop SP-303 as a drug called Provir. Results of a Phase II, placebo-controlled clinical trial of 51 participants with AIDS and chronic diarrhea were reported at the XII International Conference on AIDS in June 1998 and published in the November 1999 issue of the American Journal of Gastroenterology. After four days, participants taking SP-303 experienced a decrease in stool weight and frequency compared with those receiving a placebo. Although clinical trials indicated that the compound was safe and effective, the FDA declined to approve it, asking for further studies (which Shaman said it could not afford to conduct). Shaman then created a new subsidiary, Shaman Botanicals, which markets SB-NSF as an herbal supplement (see www.shamanbotanicals.com or call 800-987-9920). Nutritional Supplements Various nutritional supplements have been used with some success to treat chronic diarrhea. Among the most common are probiotics, beneficial microorganisms that help restore a normal intestinal environment. These include the bacteria Lactobacillus acidophilus and a related species, Lactobacillus bifidus. Antibiotic drugs often kill off friendly flora, allowing the overgrowth of harmful bacteria (C. difficile) that cause diarrhea. This can be reversed by taking acidophilus capsules, yogurt with live cultures, or the yeast Saccharomyces boulardii. Small studies indicate that S. boulardii relieves chronic diarrhea in people with HIV/AIDS.
Some studies have shown that calcium supplements can help prevent diarrhea;
calcium also is found in nondairy foods such as salmon, sardines, and
tofu. At the 39th Interscience Conference on Antimicrobial Agents and
Chemotherapy (ICAAC) in September 1999, E. Perez-Rodriguez and colleagues
reported that all 24 HIV positive participants in their study with nelfinavir-induced
diarrhea reported improvement after taking 500 mg of calcium carbonate
twice daily; 16 (67%) reported normal bowel movements. Chinese Medicine
Traditional Chinese medicine (TCM) also offers relief from nausea, vomiting,
and diarrhea. In addition to herbal remedies (e.g., "curing pills")
and probiotics, TCM practitioners use acupuncture and acupressure to
treat nausea. Acupuncture involves the insertion of fine needles into
predefined points on the body to improve the flow of qi, or vital energy;
acupressure is a similar technique that uses finger pressure instead
of needles. The primary acupuncture point for controlling nausea (pericardium
6, or P6) is located on the inside of the forearm about two inches below
the wrist. "Sea Bands" are elastic bands worn around the wrist to stimulate the P6 point; these are sold to prevent motion sickness, but some people find they help relieve nausea due to other causes.
Since the start of the AIDS epidemic, nausea, vomiting, and diarrhea
have plagued people with HIV. In the past several years, effective combination
antiretroviral therapy has dramatically reduced the incidence of OIs
that cause these symptoms; today most GI symptoms in people with HIV/AIDS
probably are related to the drugs themselves. Vomiting and diarrhea
not only are uncomfortable and limit daily activities, but also can
lead to serious consequences such as dehydration, wasting, and inadequate
medication levels. Liz Highleyman is a freelance medical writer based in San Francisco.
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Phase II study to assess the safety and efficacy of orally administered
SP-303 for the symptomatic treatment of diarrhea in patients with AIDS.
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