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Introduction

When it comes to side effects of HIV medications, the gastrointestinal tract—the gut—is one of the most commonly effected organ systems in the human body. The reason for this is simple: the gut is one of the body's first immune defenses, with the intent of allowing healthy nutrients into the body and keeping potentially harmful toxins and germs out. Although antiretrovirals (ARVs) are designed to fight HIV and ultimately do the body good, the gut considers these drugs to be harmful and will sometimes turn on its defense mechanisms to clear them from the body.

Nausea, vomiting, and diarrhea are three ways in which the gut deals with toxins it considers harmful. These are important defense mechanisms, as they help keep dangerous germs—such as bacteria, viruses, and other bugs—as well as truly harmful chemicals, out of the body. Unfortunately, these mechanisms can backfire when dealing with lifesaving medicines. While we may recognize medicines as being helpful, it can take the gut some time to figure this out. In the process, the gut goes about "business as usual," responding in some rather unpleasant ways to the onslaught of ARV treatment.

If nausea, diarrhea, and vomiting are severe or prolonged, they can lead to serious health problems and can prevent HIV meds from entering the bloodstream and from doing what they need to do. This is especially true for HIV-positive people experiencing these symptoms due to an underlying AIDS-related infection or complication. Thus it's always best to report these symptoms to your doctor, to determine if they are a side effect of treatment or a symptom of something more serious.

Fortunately, nausea, vomiting, and diarrhea—when they occur as side effects of HIV treatment—are usually mild, and tend to diminish after the first few days or weeks of treatment. But this does not mean that you need to simply live with these problems. They can have a serious impact on your quality of life and the way you go about your day-to-day activities, and they can have a negative effect on the way you view your treatment. For some HIV-positive people, these side effects can linger for several weeks, months, or years!

This lesson reviews some of the ways to manage nausea, vomiting, and diarrhea—three of the most common side effects of ARV therapy.

Nausea and Vomiting

Nausea and vomiting are two of the most common gut-related side effects of HIV treatment. Interestingly, nausea and vomiting have very little to do with the actual effects of medications on the stomach or the rest of the gut. While medications used to treat HIV and AIDS can certainly irritate the lining of the gut and cause pain or discomfort, the reason why these drugs cause nausea and vomiting actually involves a part of the brain called the "vomiting center." When the vomiting center detects certain imbalances in the body—including toxic chemicals entering the bloodstream—it signals the stomach to reject its contents. This can lead to a general feeling of sickness or "queasiness" in the stomach and, sometimes, the forceful elimination (emesis) of the stomach's contents through the mouth.

While vomiting is considered to be more severe and dangerous than nausea, many people report that feeling nauseous is far more unpleasant than vomiting. As for vomiting, if it is severe and lasts for more than a few days, it can deplete the body's fluid levels—a condition called dehydration. Prolonged periods of nausea or vomiting can also cause someone to lose his or her appetite and become undernourished. Vomiting can also prevent HIV drugs from remaining in the gut long enough to allow for proper absorption as well. If these drugs are not absorbed properly, their levels in the blood can fluctuate, ultimately leading to drug resistance.

Fortunately, the nausea and vomiting that accompanies the use of ARV medications are usually mild and tend to get better after a few days or weeks of continued treatment. The severity of nausea and vomiting usually depends on the drug or combination of drugs used, the number of times each day the drug is used, whether or not food should be taken with the drugs, along with a number of other variables particular to each patient (i.e., gender, body weight, height, age, experience with other medications in the past, etc.).

Most of the drugs used to treat HIV are known to cause either nausea and/or vomiting. However, this does not mean that everyone taking HIV drugs will experience either of these problems. It also doesn't mean that someone who experiences nausea or vomiting while using one particular drug or combination of drugs will experience these symptoms with all of the ARVs.

Managing Nausea and Vomiting

As mentioned in the previous section, most HIV-positive people who experience nausea or vomiting usually do so after starting a new HIV drug regimen. In most cases, these side effects lessen or go away completely after the first few days or weeks of treatment. As a result, most doctors encourage their patients to "stick it out." However, this does not mean that you should simply grin and bear it. Even though nausea and vomiting are common side effects of ARV therapy, they should not be considered a normal part of living with HIV—there are ways to manage these side effects to help you maintain your quality of life and to get the most out of your treatment.

When in doubt, talk to your doctor! If nausea is seriously affecting your quality of life, including your ability to eat, or your vomiting continues for more than just a few days, you should call your doctor. There are steps you can take to manage both of these side effects:

Switch treatments: One option may be to replace the offending drug with a similar drug that may not cause nausea or vomiting. Unfortunately, it is often difficult to determine which drug, when used in a combination of medicines, is the most likely culprit. Because many of the HIV drugs can cause nausea or vomiting, it can also be difficult to predict whether nausea or vomiting will actually improve (or get worse) upon switching to another drug. What's more, switching to another drug might not be possible for patients who have a limited number of drugs to choose from (i.e. they may be resistant to other drugs). As a result, switching treatments is often reserved for people who experience profound nausea or vomiting.

Prescription treatments for nausea and vomiting: A class of drugs called antiemetics—medicines that prevent or control nausea and vomiting—are available by prescription. These drugs work by blocking receptors in the brain's vomiting center. In patients being treated for cancer using high doses of chemotherapy, antiemetics are effective more than 75% of the time. In turn, they offer a great deal of potential for HIV-positive people experiencing nausea or diarrhea due to their HIV drug treatment. Unfortunately, antiemetics are not without side effects of their own: they have a tendency to make people feel drowsy or feel mildly sedated.

Some of the most commonly prescribed antiemetics include ondansetron (Zofran), granisetron (Kytril), dolasetron (Anzemet), dexamethasone (Decadron). Not all drugs are equally effective for all patients, and antiemetics sometimes work best when given in various combinations. Another option is dronabinol, THC (Marinol), a drug that contains a synthetic version of the active ingredient in marijuana. In order for any of these drugs to be effective, it's best if they are taken 30 to 45 minutes before taking any of the ARV drugs. It's also important to note that some of the antiemetics, particularly metoclopramide (Reglan), can be dangerous if it is taken at the same time as some of the protease inhibitors, including ritonavir (Norvir) and Kaletra.

Marijuana: Marijuana itself has also been reported, both anecdotally (word of mouth) and in small studies, to be effective for nausea and appetite loss (anorexia). Aside from being an illegal substance, it is important to note that smoking any substance is dangerous to the lungs and may aggravate existing lung problems, particularly asthma or bronchitis. Eating marijuana—by baking it in food (pot brownies, etc.)—is considered by some to be a safer way to experience the medicinal effects of this drug. Though the federal government still considers marijuana an illegal substance for any use, several states have legalized marijuana for medicinal use.

Healthy tips: Very often, nausea and vomiting can be managed without having to switch therapies or by having to add additional medicines to an already complicated regimen. Consider some of the following:

• Eat small meals frequently instead of two or three large ones. Large amounts of food in the stomach may make feelings of nausea worse.
• Cut a lemon and smell the slices to lessen nausea.
• Ginger has long been used in folk-medicine to dispell nausea. Many people find ginger ale or ginger tea to be helpful.
• Bland foods are easier to digest. Stick to foods low in fat but high in starches and carbohydrates to fuel the body's energy needs.
• Relax before meals and chew slowly.
• Breathe deeply and slowly when you first feel nauseated. Also, avoid odors such as smoke, perfume, and cooking odors.
• The use of Sea Bands (placed between the two tendons on the inside of the forearm about two inches up from the wrist) has antiemetic effects. These are available at many pharmacies and stores that specialize in travel products.

Diarrhea

Like nausea and vomiting, diarrhea – loose, watery stools – is one of the more common side effects associated with drugs used to treat HIV and AIDS. Having diarrhea can seriously deplete the amount of water in the body, as well as vital nutrients called electrolytes. If water is not replaced, symptoms of dehydration may follow. Symptoms include an increase in thirst, anxiety, weakness, confusion, lightheadedness and even fainting. Dehydration may also cause a decrease in urine output, dry and pale skin that doesn't have its normal elasticity, an increase in heart rate, and a decrease in blood pressure. If dehydration becomes severe, it can be a serious problem leading to collapse and even death.

Because diarrhea is a symptom of many diseases and complications that can occur in HIV-positive people – including viral, bacterial, and parasitic infections; food intolerances; and bowel disorders – it is important that you report it to your doctor. Generally speaking, diarrhea that occurs five times or more a day, for five or more consecutive days, and results in five pounds or more of weight loss, should always be reported and managed to prevent dehydration.

Managing Diarrhea

Fortunately, diarrhea is usually a short-term side effect of anti-HIV medicines. Diarrhea usually improves after a few days or few weeks of treatment. However, loose, watery stools can become a long-term problem for people taking certain anti-HIV drugs, including nelfinavir (Viracept®). While the diarrhea associated with nelfinavir doesn't usually lead to dehydration or other life-threatening problems, it can be a nuisance and may have a profound affect on a person's quality of life. Thus managing diarrhea, no matter how severe, is very important. Consider some (or all) of the following:

Make changes in your diet: Making dietary adjustments may help control diarrhea. Some foods can actually cause diarrhea – or make it worse – while others can help to relieve it. Here are some specific suggestions:

• No matter what the underlying cause of the diarrhea, the BRATT diet – consisting of Bananas, Rice (white), Apple juice or sauce, and Toast and Tea (herbal) – may help to control it.
• Foods that are high in starch – such as white rice, mashed potatoes, and white bread – are a good bet, along with oatmeal and tofu.
• Clear juices, such as apple, peach, or pear – all of which contain much needed sugar to fuel the body – are much less harsh on the gut than other types of juices that are high in acid content (e.g., orange or grapefruit juice).
• Another good tip: Eat small amounts of food five to six times throughout the day, instead of three large meals.
• Add nutmeg to foods in order to slow down the movement of material through the intestines. This works!
• Foods to avoid: Food that can make diarrhea worse include coffee and other caffeinated beverages (cola, certain soft drinks, tea, etc.), alcohol, chocolate, fried and fatty foods, spicy foods, food high in insoluble fiber such as raw vegetables, potato peels, beans, and brown rice, fat substitutes (Olean or Olestra) and highly processed foods with little nutritional value such as Twinkies, cookies, cakes, donuts, etc. Dairy products – such as milk and cheese – can also make diarrhea worse.

Increase your fluid intake: Try to drink at least three quarts of fluid per day, unless your doctor tells you not to do so. This will help to prevent dehydration and malnutrition, which may result from diarrhea. Here are some specific suggestions:

• Drink sports drinks, such as Gatorade®, which help to replace some of the electrolytes lost in diarrhea. To make a sports drink at home, add five tablespoons of sugar and one tablespoon of salt to one gallon of water. You can also flavor it with some fresh lime or lemon.
• Drink clear liquids, including clear fruit juices, ginger ale, and water.
• Drink liquids at room temperature.

Drugs that can be used to manage diarrhea: To help control diarrhea, there are several over-the-counter (OTC) remedies available, including Imodium® AD (a prescription version, loperamide, is available for those who need larger amounts of the drug), Kaopectate®, and Metamucil® (though Metamucil is commonly used as a laxative, its fiber contents can also absorb water in the colon and help control diarrhea). Some of the anti-diarrheal drugs available by prescription include Diphenoxylate (Lomotil®), pancrelipase (a pancreatic enzyme sold under many brand names), and tincture of opium. As with drugs used to control nausea and vomiting, anti-diarrhea drugs seem to work best if taken 30 to 45 minutes before taking the medication causing the diarrhea.

Consider complementary therapies: Two herbs said to be helpful in controlling diarrhea are peppermint and ginger. Drinking peppermint or ginger tea, or ginger ale, may help calm the gut and help you to regain some control over your diarrhea. Other complementary therapies for diarrhea include lactobacillus acidophilus (available in capsules and yogurt), which can help replace helpful bacteria in the gut lost during therapy with antibiotics, as well as the amino acid glutamine and the Chinese herbal blend Quiet Digestion.

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