Being Alive; August 1996
Jennifer Jensen, MS, RD

The new in question is "What's your cocktail?" Actually, some of us are just riding high on the enthusiasm of others as we manage to keep CD4 cells over 500. A "contact high"-again from the '60s. Viral loads are shooting down as fast as CD4 counts are going up. Some are getting load test results of "non-detectable" HIV. Since these new developments could mean that lives are being saved, let's make sure that the nutritional requirements surrounding the new drugs are used. Nutrition Power with proteases!

Timing Is Everything

Mostly, the new focus of nutrition is about timing of eating events and suitable adjustments for maximizing inhibitor action. If you're taking a protease inhibitor (PI) along with two members of the AZT family, a common triple combo, there are compounded side effects and even more nutritional requirements. The mix/match with other anti-HIV therapies can be critical. And they can be confusing, so get your highlighter out.

Nutritional Requirements

The first protease inhibitor (PI) to become available, Roche's saquinavir, aka Invirase, came in with a major nutritional challenge-you must take it with a full meal. Roche said it was practically useless if taken without food. It has a major malabsorption malady: at best they expect around 4% absorption, and even then only with a full-meal stomach condition.

Feasting

Logic is wonderful! Without food, like a water slide, meds just slip on down the inter-intestinal highway until finally you expel that expensive drug into the toilet! Knowing this, let's get the food to hang around better. Here's where Nutrition Power is a true manifestation of the old saying that Knowledge is Power! Know this: Fat in the stomach can keep food there for up to five hours.

Normally the stomach is supposed to acidify food ("stomach acid") and manipulate it-kind of like a washing machine. Then it becomes a food storage compartment (or "holding tank") as the churned-up food particles line up for admission to the intestines. For feasting, food should slide slowly. Since food stored in the stomach (using fat) will prolong drug transit, it makes sense to give the food a long time to go down the entire intestinal length-absorption max! For example, if you eat a tuna sandwich with avocado and mayonnaise, you have a high-fat meal. (Here, the fat types are also exceptional!) This little "tuna trick" just may best-out Roche's 4% estimates! The tuna trick can also be done with peanut butter sandwiches, cheese sandwiches, ice cream sandwiches, hamburgers, pizzas, pastries, donuts, cookies, cakes, etc. The more fat in the food, the longer the stomach will hold onto it, making it stay longer at intestinal walls for maximum absorption.

Nutrition Power doesn't stop at full-vs-empty. Saquinavir needs an extra Nutrition Power Trick: Take it with grapefruit juice! The pink juice, by the way, is full of Lycopene, a powerful carotenoid antioxidant; the colorless juice is not, and looks a little like a bottle of urine-whatever makes you happy!

Check with your pharmacist and/or dietitian about other medications that can cause potential benefit or harm if taken with grapefruit juice. There are a lot of "harm-with-grapefruit" candidates. Medications to take with food (feasting) include saquinavir (Invirase) and ritonavir (Norvir).

Fasting

In other medication-related rules, an empty stomach is called for. What that means is that slithering down the intestines alone is the way the drug works best. Otherwise it might compete with food for absorptive area in the intestinal lining. The standard rule is: "Take either one hour before or two hours after eating." And this two or three times a day!

Pay attention to timing. Crixivan (indinivir) is a fasting-type PI. Take your indinivir when you first wake up as noted-it's been well past two hours since your last feeding, usually. Wait an hour before you eat breakfast, and do not skip that meal. Depending on your next feeding time, use the fat trick to control your feasting/fasting balance to go along with your indinivir doses. If you'll settle for less benefit, why do it at all?

Nutrition Power has a helpful hint for fasting, and I do speak from experience: If you do eat between meals and you're taking a "fasting-type" drug, enjoy fruits, vegetables and clear liquids like apple or cranberry juice. Since these "simple" food types leave the stomach almost as fast as you eat them (within an hour or so), you can work in some pretty awesome nutrients even while technically you're still "fasting." Make sure you don't eat mixed foods or fatty foods. Your dietitian/nutritionist can be a big help to you here.

Common meds to take "fasted" include Zidovudine (AZT), Hivid (ddC), Videx (ddI) and the PI Crixivan (indinivir).

Hydration Matters

Don't depend on thirst to guide you to adequate fluid intake-a very bad idea. Thirst is no indicator of overall hydration. Instead, plan to drink at least two quarts daily. It doesn't have to be fancy. Any soda, safe water, lemonade or other fruit drink, will do.

Dehydration is far more dangerous than it sounds! If you're losing fluids (sweats, diarrhea, vomiting), be sure to enforce a double-on-one drinking level: two cups in for one cup out. Heavy exercise and other fun things can count as reasons for surprising amounts of "output." Use the two-for-one approach on top of that regular two quarts a day.

And one more reason for adequate hydration-your kidneys. Passing through the kidneys we'll find protein residues, drug residues and inner-tissue waters. And minerals. Crixivan is a drug that has a chance of making a kidney stone for you and I've heard that these really hurt! Fast flushing the drug through is not only inspired, it may add hugely to your quality of life! Cranberry juice has long been associated with bladder and kidney protection from microbial maladies. I think it's an excellent beverage choice and it may even protect the kidneys from stones-who knows?

Seriously

We may have only one chance with PIs. These drugs are a very powerful weapon against HIV/AIDS and results are so promising there's only one way to approach them: Total Respect. Take your meds with serious planning to get the best value. If anyone starts playing with casual attention to best benefit, everyone gets let down; the drug's effects, the doctor-and you! The new caveat is no more drug holidays. The incredible medical power can be lost simply because of sloppy timing-be really serious about your future health potential, and we'll meet up in the old folks' home! As always, first do no harm. If any of this advice is, or seems to be related to adverse health consequences, contact your doctor or your nutritionist.

(Jennifer Jensen, MS, RD, is in private practice and offers a sliding scale fee reduction for HIV clients. Supplements are provided at cost. She always welcomes your call at 310.450.5581, or send e-mail to NutPower@aol.com.)

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