Diarrhea

Diarrhea -- an increase in the frequency and decrease in the consistency of stools -- can be caused by many antiretrovirals. This is an important side effect to keep in check, and any diarrhea that is frequent, watery or lasts for more than a couple of days should always be reported to your doctor.

The two medications most commonly reported to cause diarrhea are the protease inhibitors nelfinavir (Viracept) and ritonavir (Norvir), but many other meds may also cause this problem, including:

• indinavir (Crixivan)
• saquinavir (Fortovase)
• amprenavir (Agenerase)
• ddI (Videx EC)
• ddC (Hivid)
• d4T (Zerit)
• 3TC (alone in Epivir and also in the combination drugs Combivir and Trizivir)
• abacavir (alone in Ziagen and also in the combination drug Trizivir)
• nevirapine (Viramune)
• efavirenz (Sustiva)
• the anti-herpes drug acyclovir (Zovirax)
• many antibiotics and other meds

In other words, a large number of meds can be implicated in the problem of diarrhea. Obviously, combining these meds can make it difficult to tease out a single culprit. If the onset or sudden worsening of diarrhea is tied closely to beginning a medicine, it's a likely suspect. In some cases, the diarrhea may diminish after a period of time on the drug, but too often it will become your daily companion.

Tips for Handling Diarrhea

If switching drugs is possible, that may be the best solution and will usually result in a quick resolution of the problem. However, since more than one cause often contributes, truly effective treatment requires aggressive diagnosis to pin down all possible factors. In addition to medicines, these can include:

• infections and parasites -- check for them with aggressive diagnostic measures and treat anything found
• fat intolerance and malabsorption (very common in PHAs, even in earlier disease stages) -- cut back on dietary fat and take lipase, the fat-digesting enzyme (found in the better pancreatic enzyme formulas) with meals
• lactose intolerance (very common in PHAs)-- eliminate or decrease dairy products and take lactase enzyme when you do consume them
• excessive sugar or caffeine -- cut back on 'em
• stress -- find a way to chill out or consult with a therapist

When all causes can't be eliminated, using standard anti-diarrheal agents, such as the following, may help relieve symptoms:

• Kaopectate
• Pepto-Bismol
• anti-motility agents (Imodium, Lomotil, tincture of opium, paregoric or opiates)
• luminal-acting agents or those that act in the intestinal passage (cholestyramine, pectin, Kaolin or fibre supplements)

Here are some other options for the runs:

• Shaman Botanicals' SB Normal Stool Formula is a tree sap extract that many PHAs have reported helps reduce or eliminate med-induced runs.
• The amino acid L-glutamine, taken in doses of 5-30 grams daily (a powdered form is best; mix it in water or juice), can both help to heal damaged intestines and reduce the diarrhea by enhancing water and sodium (salt) absorption across the wall of the small intestine.
• Friendly bacteria, such as L. acidophilus, may also help relieve the symptom.
• Ground flax seeds (also called flaxmeal) will also sometimes help to relieve diarrhea and heal the intestines.

For diarrhea caused by protease inhibitors (PIs):

• Calcium taken in doses of 500 mg, twice per day, may work. Initially, a small study showed calcium therapy to be very effective for reducing or eliminating diarrhea caused by nelfinavir (Viracept), and since that study's publication there have been many anecdotal reports that it also works for diarrhea caused by other PIs.
• Another small study showed that a pancreatic enzyme formula containing a high level of lipase (Digestive Care, Inc.'s Pancrecarb) taken with meals significantly improved stool consistency in those with PI-caused diarrhea.

Increasing your intake of foods that contain soluble fibre can help since they absorb water and expand, binding together the intestinal contents. This bulks up the stool and slows the passage of food, particularly when there is a lot of fluid in the stool. Examples of foods that contain soluble fibre include the following:

• peeled apples or apple sauce made from them
• other fruits such as apricots, peaches, pears, plums, grapes, melons, nectarines, bananas
• grains such as oatmeal, oat bran, white rice and barley
• soluble fibre supplements like psyllium (Metamucil) that you dissolve in a glass of water and drink

Fibre intake should be slowly increased to help limit the increase in intestinal gas that it can cause.

For as long as diarrhea continues, it is crucial to:

• Consume plenty of calories (eat more and make every bite count toward high-quality nutrition) and
• drink plenty of healthful liquids (water, juices, herb teas, broth and fruit juice smoothies) to replace what's being lost.

Remember that it is crucial to prevent dehydration when you are suffering from diarrhea, regardless of the cause. Drinking lots of water daily is very important. You should consume at least 1.5 litres of water every day.

With serious diarrhea, it is important to rebalance the body's electrolytes, including sodium, potassium and chloride. Drinking vegetable and fruit juices, nectars or broths (diluted with water to enhance absorption) can help. However, more concentrated sources of electrolyte minerals may be needed. Gatorade is often recommended but it is not a very concentrated source of the minerals and is also loaded with sugar, which could actually worsen the diarrhea. Infalyte and BestLyte are better choices.

Another possibility is the use of the oral rehydration salts recommended by the World Health Organization, which are available through many pharmacies at low cost. The other inexpensive option is to mix your own solution with a teaspoon of light salt (which contains potassium mixed with sodium) and a quart of orange juice or apricot, peach or pear nectar (diluted with water); sweeten with a tablespoon of pasteurized honey, if desired. To add soluble fibre to this mix, dilute the nectar half and half with rice water (made by boiling four parts water and one part rice until the rice is tender, and then straining off the rice water). This rice water can also be drunk on its own as a source of both hydration and soluble fibre.

The following foods and liquids should be avoided because they can make diarrhea worse. Try to eliminate or at least cut back on these as much as possible:

• coffee and other caffeinated beverages
• alcohol
• chocolate
• fried and fatty foods
• spicy foods
• high-sugar foods or liquids