Important note: Information in this article was accurate in June 2000. The state of the art may have changed since the publication date.
One of the side effects associated with protease inhibitors (PI) is diarrhea. During the first weeks of therapy the diarrhea (and other side effects) may be most common and severe. In as many as one third of users, PI-associated diarrhea can persist beyond the first month of therapy, which can reduce a PHA's enjoyment of life and may have a negative impact on his or her health. Indeed, one study has found that subjects taking nelfinavir and who did not experience diarrhea had "significantly greater increases in CD4+ cell counts than did [subjects with diarrhea]."
No large, well controlled and designed study to test the efficacy of diarrhea remedies in PHAs has been done. As a result, it is difficult to compare one study to another, so doctors and patients will have to experiment to find out which product works best.
Doctors in Colorado have recently published a list of products that may help some PHAs manage their PI-related diarrhea. The list includes the following:
Some of these products can be found in drug and health food stores. Some can also be ordered via the Internet or from buyers' clubs. The cost estimates provided by the researchers (which appear later in each of the sections below) are given in American dollars.
Oat bran helps to thicken stools and increase the time food spends in the intestinal tract. Oat bran also helps increase the growth of friendly bacteria in the intestine. In one experiment, 51 PHAs took 1,500 mg of oat bran in the form of tablets each time they took their PI. The PIs used in the study were as follows:
After two weeks of therapy, 84% of subjects said that their diarrhea had decreased either "moderately or dramatically." Oat bran tablets cost less than $5US per month.
Psyllium is a concentrated powder made from vegetable material. This substance absorbs water in the intestine, thereby helping to reduce diarrhea. In a telephone survey of nelfinavir users, 11 of 20 PHAs using psyllium said that they had "less frequent stools" compared to when they did not use this product.
Psyllium is also available in the form of fibre bars. In another study, 16 PHAs ate two fibre bars one hour before bedtime for two weeks. Fourteen subjects completed the study, thirteen of whom reported that their diarrhea had decreased. Fibre bars containing psyllium cost about $10US per month.
Derived from opium, Imodium slows down the passage of waste through the intestine and reduces the amount of fluid released by intestinal tissues. Slowing the passage of substances allows the intestine to reabsorb water and helps to thicken the stool. In reviewing the medical records of 38 subjects given Immodium for PI-related diarrhea, researchers found that only about one third found that the drug reduced the number of stools produced. The monthly cost of loperamide is around $10US.
Fifteen PHAs using nelfinavir took calcium carbonate 500 mg twice daily. After 48 hours 87% of subjects reported "normal stools." These results have not been confirmed in another published study. The monthly cost of calcium is about $5US.
This drug also slows down the movement of waste in the intestine. Reports from doctors suggest that this drug can be helpful, although it can cost around $130US per month depending on the amount used.
Enzymes produced by the pancreas gland include the following:
By reducing the amount of fat in stools, products containing enzymes increase the thickness of stools and decrease their number. Two products containing pancreatic enzymes have been studied for PI-related diarrhea:
In one study, 55 PHAs experiencing diarrhea "associated with saquinavir or nelfinavir and who [did not] respond to common over-the-counter products" received 325 mg of Viokase with each meal. In as little as 12 hours, more than 80% of subjects reported relief, and diarrhea stopped in the following proportions of subjects:
Some subjects complained of abdominal cramps. Viokase tablets costs about $30US per month.
In another study, 26 subjects using nelfinavir who were experiencing more than two loose stools per day were given two tablets of Ultrase MT 20 with meals and snacks. Twenty-five subjects had fewer loose stools after using this product. The enzymes in these products do not appear to reduce the level of nelfinavir in the blood. Ultrase MT 20 costs about $100US per month.
This product is an extract of the sap of a tropical plant. The sap has been used by native people in South America for the relief of diarrhea. It is not clear precisely how this drug works. Results from at least one placebo-controlled study, where subjects were given SP-303 500 mg every six hours for four consecutive days, found statistically significant reductions in the weight of stools produced. No side effects were reported. The drug costs about $54US for a month's supply and can be purchased on the Internet at www.shamanbotanicals.com.
1. Sherman DS and Fish DN. Management of protease inhibitor-associated diarrhea. Clinical Infectious Diseases 2000; June - 30(6):908-14.
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