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Nausea, Vomiting and Appetite Loss
Part of A Practical Guide to HIV Drug Side Effects

By Lark Lands

2013

Nausea, Vomiting and Appetite Loss

Credit: Kevin Massé

Figuring Out the Cause

Nausea, or feeling sick to your stomach, is something everyone feels sometimes. It can also lead to vomiting, or throwing up. Sometimes it passes after a few hours or within a day. When nausea causes repeated vomiting over time, it can result in serious malnutrition, dehydration and imbalances in some of the normal chemical compounds, called electrolytes, in the blood.

Appetite loss, or not feeling the urge to eat, can accompany nausea, but it can also occur on its own. It may be harder to notice, but it can be even more serious when it leads you to not consume enough nutrients to maintain your health.

Keeping notes that detail your problems can help your doctor know how to successfully address them. Keep track of:

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While medications can cause nausea, vomiting or appetite loss, there are other things that can also cause these symptoms. Your doctor should run blood tests and carry out an overall medical workup to see if liver problems, infections, hormone deficiencies or other medical conditions are contributing to your nausea or appetite loss. There are many possible causes for these symptoms; often, more than one factor will be contributing to them.

Not all doctors approach the problems of nausea, vomiting and appetite loss aggressively. If you feel your symptoms are not being effectively managed, tell your doctor they are seriously affecting your life and your ability to eat a healthy diet. Emphasize that the search for a cause or causes of your symptoms must continue.


Infections

Appetite loss and nausea can be caused by infections. Almost any infection can result in decreased appetite, along with fever, fatigue and generally feeling lousy. Nausea can be caused by certain infections, including many common bacterial and viral ones. The organisms that cause food poisoning will often cause sudden and sometimes severe nausea, so food poisoning should always be considered.

Some infections and cancers that can also cause nausea in people with HIV include H pylori gastritis, secondary syphilis, cryptococcal meningitis, cryptosporidiosis and other parasitic infections, viral hepatitis, Mycobacterium avium complex (MAC), severe toxoplasmosis and lymphoma. Some of these are uncommon in people whose HIV is well treated, but it is always important to consider the possibility that an infection is contributing to nausea and appetite loss, and take all necessary steps to diagnose and properly treat it.


Antiretroviral Drugs, Other Medications and Supplements

Nausea is a common side effect of antiretroviral drugs, pain medications, cancer chemotherapies, radiation and many other therapies. Virtually all the currently available antiretroviral drugs can cause nausea, though some (for example, protease inhibitors) are more likely to cause this problem than others. It is also one of the symptoms of the rare abacavir hypersensitivity reaction. See the section in Less Common Side Effects for more information.

Drugs used to treat many infections can cause nausea. One nausea-causing drug that people with low CD4 counts can be taking is the antibiotic Bactrim/Septra, used to prevent Pneumocystis pneumonia and some other germs. Most people tolerate this drug well, but some people develop significant nausea and may need to switch to a different preventative drug.

Pain medications cause nausea in a large percentage of people. If these drugs are possibly contributing to your nausea or appetite loss, discuss possible alternatives with your doctor. Cancer chemotherapies and radiation can also cause very severe nausea and it is very important to address this in order to continue to treat the cancer.

Some people experience nausea from certain supplements, such as fish oil. This can be more common if the supplement is taken on an empty stomach. Pharmacists advise people to watch for side effects when they start a supplement and not to begin taking a new supplement when they are changing any other medication.


Liver Problems, Pancreatitis, Testosterone Deficiency, Depression

Testing to assess the possibility of liver problems is important in determining the cause of nausea and appetite loss. If tests show the possibility of liver damage, therapies to support the liver and reverse damage or prevent its worsening are important to counter nausea and appetite loss.

People with HIV are at an increased risk of developing pancreatitis, and this risk may be higher when people take certain medications or drink a lot of alcohol. If severe abdominal pain starts suddenly and accompanies nausea and vomiting that lasts several hours, especially after eating or an alcohol drinking binge, pancreatitis is a possibility. These cases need immediate medical care. For more information on this serious condition see the section Less Common Side Effects.

Testosterone deficiency is common in both men and women with HIV and can lead to decreased appetite. It is important to have your testosterone level tested for many reasons. If testing shows your levels to be low, testosterone replacement may improve your appetite. For a full discussion, see the section on hormone changes in the Emotional Wellness section.

Depression occurs in some people with HIV and, when present, frequently causes appetite loss. If depression is a problem for you, it is very important to get the treatment you need. For a full discussion, see the section on Emotional Wellness.


Changing your Medications or Your Medication Schedule

If the nausea or appetite loss you are experiencing appeared just after you began taking a new medication, your drug is a possible cause of your symptoms. If the problem doesn't improve over the next few weeks, talk to your doctor about it. In many cases, these side effects diminish or disappear after a short time on the medication, so it may be worthwhile to stick it out rather than immediately stopping or switching drugs. Remedies that can help with short-term nausea or appetite loss, including anti-nausea drugs, are listed later in this section.

Another factor to consider is the timing of your medication. Consult your doctor or pharmacist to determine whether taking your drug at a different time of day could help. Some drugs cause less nausea when taken with a full meal; others should be taken on an empty stomach.

Changing Your Eating Habits

To cope with ongoing nausea or appetite loss, try changing your eating habits. Eat on a schedule and substitute smaller meals and frequent small snacks for three big meals. Allowing your stomach to remain empty for too long tends to increase nausea. This approach will also help prevent low blood sugar, which can worsen nausea. Even if you don't feel hunger pangs by the next scheduled meal or snack, do the best you can to eat at that time. Anything that perks up your appetite and doesn't make you feel nauseated should be tried. For example:

If you experience recurrent vomiting, it is very important to rebalance your electrolytes. See the suggestions in the section Diarrhea, Gas and Bloating.


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Countering Nutrient Deficiencies

Ongoing nausea or appetite loss can lead to a vicious cycle where reduced food intake results in inadequate levels of nutrients. That lack of nutrients creates malnutrition-induced appetite loss, which results in continuing reduced nutrient intake. When this cycle occurs, it is necessary to restore your body's nutrient levels to normal. The solution usually involves a combination of appetite boosters, high-nutrient foods and supplementation.

A multivitamin mineral supplement can help make up for not getting enough micronutrients. If nausea makes taking pills difficult, liquid multivitamins are an option. The micronutrient deficiency most known for causing appetite loss is zinc. Although zinc is contained in most multivitamins, you can restore levels more quickly by adding it as a separate supplement (75 mg daily, taken with any meal). People often add a copper supplement (5 mg daily, taken at a different meal) to reduce the risk of heart problems. However, too high levels of copper can lead to liver damage, so talk to your doctor before starting a copper supplement.

Drinking a liquid meal may seem a lot easier than eating one. Try a home-made blended soup or a nutrient-rich, high-calorie smoothie. Experiment by blending together the following ingredients:

Among the best of the available protein powders are the whey protein products. Just don't overdo protein powders. Remember that too much protein can actually strain the kidneys and cause diarrhea.

If you don't want to create your own supplement, look for supplemental drinks that are low in sugar, use predominantly medium chain triglycerides (MCTs), are moderately high in good-quality protein and high in calories overall.


Anti-Nausea and Appetite-Stimulating Drugs

When all of the above suggestions fail to resolve your problems with nausea or appetite loss, it is very important to discuss with your doctor or pharmacist the use of medications to counter them.

The most commonly used drug in Canada for nausea, even in hospital emergency rooms, is dimenhydrinate (Gravol and its generic equivalents). You may find you can get effective relief from mild to moderate nausea with a children's dose of Gravol rather than the adult dose. The children's dose also helps to avoid drowsiness. If you are taking an adult dose of Gravol and not getting relief from nausea, you should see your doctor or pharmacist as soon as possible.

There are a large number of prescription medications used in the treatment of severe nausea and appetite loss. If one does not work, another one might; or a combination of medications may do the trick. The best results are sometimes seen using drugs that act in different ways. For example, some drugs work by emptying your stomach more quickly, while others block the signals to and from the brain that otherwise result in nausea.

Talk to your doctor or pharmacist before switching drugs. Drugs can interact with one another to cause side effects or other problems. Always ask your pharmacist to check for drug interactions with your current antiretrovirals and other medications before trying any of these agents.

Some of these anti-nausea medications can be given in different forms. For people with severe nausea that makes keeping pills down difficult or impossible, quick-dissolve tablets, suppositories, patches, injections or intravenous infusions are important options.

One warning on medication choices: megestrol acetate (Megace) was prescribed in the past for appetite stimulation but it can suppress production of testosterone, which is already low in many people with HIV. Testosterone deficiency can contribute to appetite loss and can also cause breast enlargement in males. Talk to your doctor about alternative medications that may be right for you.


Other Anti-Nausea Agents

Studies have shown ginger to be an effective anti-nausea agent, even in chemotherapy-induced nausea. Because the anti-nausea effect of ginger requires it to be physically present in the stomach, consume it a few minutes prior to eating, drinking or taking medications. It can be taken in capsule form or as a ginger syrup that is added to water to make a beverage you can drink throughout the day.

Or make ginger tea by chopping or grating 30 to 45 ml (two or three tablespoons) of fresh ginger root and adding it to 250 ml (a cup) of boiling water. Simmer for five to 10 minutes and drink throughout the day. Chopped ginger root can also be added to many dishes where it will add flavour, as well as help counter nausea.

Medicinal marijuana is effective as an appetite stimulant and anti-nausea agent, so it can be a good choice for people who need both. Preparing a healthy meal prior to using marijuana can help ensure its appetite-stimulating effects are used to the best nutritional benefit. The cannabinoid drug nabilone (Cesamet) is sometimes used for severe nausea and vomiting. Smoking marijuana can be hard on your lungs, so some people prefer it baked into brownies or cookies. All cannabinoid agents can leave people feeling "stoned." There is controversy over the link between marijuana use and the medical condition called psychosis. People with a predisposition to psychosis should talk to their doctor before using marijuana.


Acupuncture and Acupressure

Both acupuncture, which uses needles at energy points in the body, and acupressure, which uses physical pressure on energy points, can be helpful for nausea. Acupressure bands, most commonly sold as remedies for motion sickness, are one simple way to get help with nausea. These bands are available at many pharmacies, health food stores and from some health practitioners.


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