It is useful to find out the cause of diarrhea in order to provide effective treatment. One of the most important tests is the CD4 count, as this value shows the strength of the immune system. Generally, the lower the CD4 count (below 200 cells/mm3) the higher the chance of developing an OI. Microbiological evaluation of a stool specimen is necessary to rule out infectious pathogens (e.g., salmonella, shigella, campylobacter, C. Difficile toxin, ova and parasite, cryptosporidia, Isospora, cyclospora, microsporidia, Giardia, etc.) and fat malabsorption. This is done by providing the medical provider with a stool sample, which is then sent to a laboratory for analysis. Routine blood tests are also helpful to objectively check the severity of the diarrhea, such as electrolyte abnormalities and state of hydration. Finally, a thorough medical check-up is necessary to document diet history, medications and herbal products used currently or in the recent past.
What are these agents and where can they be found?
Glutamine is a non-essential amino acid that is used as an energy source for certain cells. It is reduced with conditions of metabolic stress, long-lasting illness, gastrointestinal tract diseases and surgery. Reliable sources of glutamine include Baxter Healthcare and Novartis Nutrition Corporation.
Calcium is known to act as a constipating agent, and therefore may reduce diarrhea. Calcium can be purchased OTC in various formulations, including calcium carbonate and calcium citrate.
Psyllium is a concentrated vegetable powder that acts as a stool bulking agent on one hand, and a laxative on the other. Side-effects include bloating and flatulence (gas). The taste of psyllium is often a complaint, so it is also available in the form of fiber bars. Psyllium is available at many grocery stores and pharmacies, in products such as Metamucil.
A good source of soluble fiber, oat bran adds bulk to stool and moves the digested food quickly through the intestines. Like psyllium, it can cause bloating and flatulence. Oat bran can be purchased OTC in tablet form.
SP-303 is found in the South American Croton lechleri plant. It has been shown to decrease stool weight and stool frequency. For many years it has been used by the people of South America for the relief of diarrhea and has been more recently studied in the treatment of HIV-associated diarrhea. An herbal product, SB Normal Stool Formula contains SP-303 and can be purchased from the website of Shaman Botanicals, San Francisco, CA (www.shamanbotanicals.com).
The combination of lipase, amylase, and protrease are the pancreatic enzymes known as pancrealipase. They reduce the fat content of stool; increasing stool consistency and decreasing stool frequency. Patients may also report a reduction in bloating, flatulence, and stomach cramps. Pancrealipase is sold both OTC and by prescription. It is important to note that the products have different amounts of enzymes and various formulations (enteric coating preferred). The products available by prescription include Ultrase MT-20, Viokase and Pancrecarb (studies of the first two are included in the table below). Side-effects of pancreatic enzymes include nausea and stomach cramps.
Severe diarrhea may be linked with malnutrition. It is important that foods and beverages that are tolerable be consumed on a daily basis. For people who do not absorb food well, nutritional supplements may also be helpful to reach better nutritional status. Included in this category are "elemental" products such as Peptamen and Subdue. These products may be ordered via a prescription from your medical provider, although keep in mind that such products may or may not be covered by the health insurance carrier. For severe cases of diarrhea and associated malnutrition, alternate nutrition support may be indicated. Delivery of nutrients via tube feeding or total parenteral nutrition are such options.
|Review of Studies Regarding the Management of PI-Induced Diarrhea|
|Medication||Over-the-Counter (OTC) or Prescription||Study Design||Dose||Number of Subjects (PI Used)||Study Results|
|Glutamine||OTC||Randomized, double-blind, placebo-controlled crossover study||10 gm three times daily||25 (nelfinavir)||Significant decrease in diarrheal severity and improved QOL (quality of life) in both treatment groups|
|Calcium||OTC||Open-label, prospective trial||500 mg twice daily||15 (nelfinavir)||13 (87%) reported normal stools; 15 (100%) reported decrease in symptoms|
|Psyllium||OTC||Survey||1-2 Tbsp, 1-3 times daily||77 (nelfinavir)||20 patients tried psyllium; 55% reported less frequent stools, 40% reported improved stool quality|
|Oat Bran||OTC||Open-label, prospective trial||1,500 mg with each dose of PI medication||51 (43% nelfinavir, 27% ritonavir/ saquinavir, 30% other)||Frequency of diarrhea decreased from a mean grading score of two (4-7 loose stools/day) to 1.04 (<3 loose stools/day); 84% had improved symptoms|
|SP-303||OTC||Randomized, double-blind, placebo-controlled trial||500 mg every six hours for four days||51 (PI not specified)||Reduction in stool weight and frequency compared with placebo group|
|Ultrase MT 20||Prescription||Retrospective trial||1-2 tablets with meals and snacks||26 (nelfinavir)||25 patients (96%) had a decrease in # of stools per day|
|Viokase||Prescription||Open-label, prospective trial||325 mg||55 (19 saquinavir, 36 nelfinavir)||87% reported bowel control with no further diarrhea, most had relief within 12 hours|
Susan Basinger, R.D. works at the Owen Clinic, University of California San Diego Healthcare. Address correspondence to firstname.lastname@example.org or phone (619) 543-6763. References are available upon request. (Thanks to Moira Mar-Tang for her assistance with editing this article.) This article is supported by an unrestricted educational grant from Agouron Pharmaceuticals, Inc.