02.27.09
Nepal Journey
Notes from the Valley—
George M. Carter
In February, I returned to Kathmandu, Nepal, a city of about 700,000 nestled in the valley below the foothills of the mighty Himalaya mountains. I had visited several times before but it has been 5 years since my last visit. So it was about time! The journey was not so difficult (13 hour direct flight to Delhi) and melatonin significantly attenuated jet lag. I spent one night in Delhi before heading quickly to Kathmandu where, upon arriving, I was greeted by Roshan (BDS Program Officer) and their inestimable and cheerful driver, Bappu.
The dust and smells were as I remembered—and while somewhat noxious, always a relief after the intensity of India. The big change was the lack of power. During my visit (and for some weeks before and since), power was only on around 6 hours per day. And at seemingly random times. Many places had generators, loud, smelly, running on diesel. There’s a major problem (along with garbage disposal) that begs for clean solutions like solar and wind!
In the summer of 2001, I got an email from a fellow from Nepal, Sunil Pant. At first, I didn’t know who he was—he was asking for help to start a condom distribution program. Then it dawned on me that he was a friend of a guy I had met, Michael Daube, who was doing some of his own pretty amazing work over there (see www.citta.org for more information about him).
So I figured he was a good guy. Around this time, a group of us were establishing the Foundation for Integrative AIDS Research (FIAR) (www.fiar.us). Our finance guy had some money so I arranged to send over some condoms. At the time, I had no idea what Sunil might do with the shipment. Their access to reliable latex condoms was nonexistent. (Later, we sent over water-based lube until a company in India began finally manufacturing it with the help of the inestimable NAZ Foundation – www.nazindia.org/.)
I envisioned perhaps a kiosk where a brochure and condoms might be distributed. I knew that the word was that the HIV epidemic in Nepal was mostly driven via unprotected heterosexual sex and sharing syringes among injection drug users. Little did I know that Sunil had other plans!
He assembled a remarkable group of metis, males who dress and/or identify as female. They had trainings on how HIV is transmitted, how to use condoms, etc., provided by large donor groups. And then they went to parks where men have sex with men (MSM). The notion that there were no MSM in Nepal was obliterated. And thus was born the Blue Diamond Society (www.bds.org.np).
Eight years later, things have grown considerably! Through much struggle, violence and some police oppression, BDS perservered and now operates in 20 cities and 16 districts throughout Nepal. Their programs consist of:
• HIV Prevention Programs (run by Salina)
• HIV/AIDS Care and Support Programs (providing HIV testing, some blood work, antiretrovirals, multivitamins (provided through NYBC), meditation, massage and spiritual and emotional community support)
• Assuring Lesbian, Gay, Bisexual and Transgendered (LGBT) rights in the developing Nepali Constitution
• Environment Issues
Sunil also ran for Parliament last year as an openly gay man—and won! In addition, lawsuits brought by BDS and other organizations have brought the Nepal Supreme Court to the decisions that the right to marry is not gender-based and issued a directive to the Congress to assure marriage rights for the LGBT community. Nepal, having recently shifted from a Kingdom to a Republic, is working on its Constitution and they are hard at work drafting language to assure LGBT rights.
In Kathmandu, I visited three BDS sites during my stay. The main office building is one I remember from previous visits (and indeed, in the early days, crashing there some nights!) Just down the road is a newly-acquired smaller building that houses their Prevention programs. At the time of my visit, they were working on a video documentary about LGBT rights and issues. I worked with Salina and friends on the translations and text.
We drove out toward the Ring Road (that surrounds Kathmandu) in the eastern end of the city where we visited the Care and Support Building, run by Rajesh and friends. Care and Support has in the main building, an exam room, waiting area with TV (when there is power!), a doctor’s office with a small pharmacy and a nice large kitchen. Outside, there is another room that serves as a meeting center and meditation room. The roof of the main building is also used and is currently undergoing renovation.
Pradeep Khadka also explained to me several other programs BDS is working on. Their website is currently being revamped and more content added to it. They have plans for several other websites as well. In addition, Page Six is a glossy news magazine that features, embedded among health, fitness, celebrity and other such news, articles about the work of BDS, prevention and treatment issues and other pertinent information. I understand it is the second most popular publication in Nepal!
I also met with Prakash Jha who is the BDS point person on the Environmental Initiatives. These got their impetus with the horrific floods suffered in the summer of 2008 in the southern part of Nepal that borders India known as the Terai region. The floods were seen as a direct result of global warming. Indeed, as I flew past the Himalayas, where the great snow-capped mountains stood there were also many dark patches that should, at this time of year, be covered with snow.
We discussed his ideas for anaerobic digestion of garbage (rather than burning it) to produce fuel. With the election of the “green jobs” man, Barack Obama, I expressed a hope and encouragement that perhaps there would be funding available to cover start-up costs for solar and wind generators. Better, I think, than hydroelectric, which degrades the environment and indeed, a large dam in China has been implicated in the horrific earthquake of May, 2008 that killed over 80,000 people.
I’m also grateful to my upstairs neighbor, Leslie, who not only cared for my cats, but relinquished her copy of McKibben’s Deep Economy which I brought over. The man has some terrific ideas altogether!
On a fine Saturday, Valentine’s Day, there were two events. First was a celebration of Pink Triangle Day in near Durbar Square at the Basantapur temple complex. A beautiful area, many BDS members and supporters showed up to express the loving relationships of the Third Gender. A long sheet was opened out slowly and passers-by were asked to sign it in support of the rights of the LGBT community in Nepal.
Being an American, I half expected to see some sign of disgust, protest or ugliness. But Nepali people are far more supportive, open-minded and open-hearted than many of my fellow citizens in the United States. It was greatly encouraging to see people not only curious and engaged as to what was going on but more than happy to sign the sheet! By the end of the day, the (10-foot?) long sheet was filled.
Later that day, Bappu drove Sunil, Prakash and I to the mountains just outside of Kathmandu to the Tapoban Meditation Center of the late, great Swamiji Osho. We went in part to see a biodigestor that Prakash had installed that is designed to take the waste from the community and transform it into biofuel. A first, small demonstration project that it is hoped will serve as a model for a wider network of such projects throughout the nation.
Finally, there were grave concerns about the process of the selection of Sub-Recipients (SR) for Round 7 of the UN’s Global Fund for AIDS, TB and Malaria (GFATM). The process appears to have been corrupt and rife with conflicts of interest, at least for the portion relating to LGBT issues. We worked on relevant letters and FIAR sent a letter to Michel Kazatchkine and others at GFATM. At the very least, closer scrutiny will be paid to assure that the SRs will live up to their contractual obligations. However, our hopes are not high that the monies will be well utilized. The situation has also resulted positively in a closer examination of the transparency and inclusiveness of the Country Coordinating Mechanism for Nepal. It is hope that these issues will be redressed for Round 8.
Altogether, the journey, while far too short, was productive and fascinating.
My grateful and deep thanks to all the friends at BDS who helped to make my visit both productive and enjoyable! And to NYBC and FIAR for their support that made the journey possible.
If you would like to see more of the journey to Nepal, visit the URL below for some photos:
http://picasaweb.google.com/gmcFIAR/NepalJourneyFeb09?feat=email#
02.26.09
Cordyceps PS: some references
Of interest to practitioners: NYBC now stocks Cordyceps PS (Health Concerns).
Cordyceps sinensis has held a place in Traditional Chinese Medicine (TCM) for over 2000 years. Among the disorders it has been applied to: liver disease, respiratory disease, renal dysfunction, heart disease and hyperlipidemia. It has also been studied as an immune system modulator and as an adjunct therapy for some cancers.
Note: For those interested in use of this product, NYBC stresses the importance of consulting with a practitioner experienced in TCM. See the list of referrals on the NYBC website; or contact NYBC directly for additional referral information.
References:
J.S. Zhu, G.M. Halpern and K. Jones. The scientific rediscovery of an ancient Chinese herbal medicine: Cordyceps sinensis. Parts I and II, Journal of Alternative and Complementary Medicine 3 and 4 (1998).
J. Chen, W. Zhang, T. Lu, J. Li, Y. Zheng and L. Kong. Morphological and genetic characterization of a cultivated Cordyceps sinensis fungus and its polysaccharide component possessing antioxidant property in H22 tumor-bearing mice. Life Sciences Volume 78, Issue 23, 1 May 2006, pp. 2742-2748.
02.25.09
Sterinols (or “sterols”) for cholesterol control and other applications
The Canadian AIDS Treatment Information Exchange (CATIE) provides this background on “sterinols” (or “sterols”), which are plant-derived fats. We’ve encountered sterinols in recent years as applied to cholesterol control. (See, for example, the NYBC entry on the Douglas Labs product Cardio-Edge, which contains sterinols along with other components that can support healthy cholesterol levels.) But, as this CATIE fact sheet reminds us, there was an earlier wave of interest in sterinols to support immune function. And, sterinol-based products have also been studied for their anti-cancer properties, and have been used to support prostate health.
Sterinols, or sterols, are plant fats. They can be derived from virtually all plants, but their concentrations vary. Sterinols are found in fairly high concentrations in the oils of unprocessed seeds and nuts and, to a lesser extent, in fruits and vegetables. Unfortunately, modern diets are often deficient in these foods, and the refining of food products reduces the amount of sterinols present. These nutrients can’t be manufactured by the human body, and you must eat them daily to maintain a stable amount in the body. These plant fats are structurally similar to cholesterol and may reduce cholesterol levels by decreasing the body’s cholesterol absorption. They may also be important for maintaining the health of the immune system. Certain sterols look promising in breast and prostate cancer cell line studies.
In the late nineties there was some interest in the application of sterinols to the treatment of HIV. Mostly this interest was in resource limited settings with no access to antiretroviral drugs. A preliminary study, conducted in South Africa, found some changes in immune system functions as a result of the sterinol beta-sitosterol (sold under the brand name Moducare), although the clinical implications were not clear. Unfortunately, for people with severe immune suppression (fewer than 200 CD4 cells/μl), this sterinol did not improve their health. The South African study was not a controlled clinical trial. Therefore it is not known what role sterinols may have, if any, in the management of HIV infection without further study. Despite the lack of clear clinical evidence, Sterinol products are being widely marketed to PHAs.
Some PHAs are incorporating oils rich in sterinols into their diet, including the oils of sesame and pumpkin seeds that, preferably, are organically grown. In general, high-quality oils are those that are cold-pressed and then packaged in dark containers. Sterinol supplements have been used in Germany for many years for prostate problems and reportedly have no side effects other than an occasional mild irritation of the stomach.
Read the entire CATIE info sheet, with references, at
http://www.catie.ca/herb_e.nsf/TOC/3D57CBD44F40DB188525697A0077858F?OpenDocument
02.23.09
Horse Chestnut for chronic venous insufficiency: Fact sheet from NCCAM
The National Center for Complementary and Alternative Medicine, one of the research centers of the federal government’s National Institutes of Health, provides an online fact sheet about the medicinal botanical Horse Chestnut.
Here’s an excerpt:
What It Is Used For
For centuries, horse chestnut seeds, leaves, bark, and flowers have been used for a variety of conditions and diseases.
Horse chestnut seed extract has been used to treat chronic venous insufficiency (a condition in which the veins do not efficiently return blood from the legs to the heart). This condition is associated with varicose veins, pain, ankle swelling, feelings of heaviness, itching, and nighttime leg cramping.
The seed extract has also been used for hemorrhoids.
How It Is Used
Horse chestnut seed extract standardized to contain 16 to 20 percent aescin (escin), the active ingredient, is the most commonly used form. Topical preparations have also been used.
What the Science Says
Small studies have found that horse chestnut seed extract is beneficial in treating chronic venous insufficiency and is as effective as wearing compression stockings.
There is not enough scientific evidence to support the use of horse chestnut seed, leaf, or bark for any other conditions.
Read the entire fact sheet at
http://nccam.nih.gov/health/horsechestnut/#
See also the NYBC entry Horse Chestnut Pro (MMS) for further information and recommendations for use.
02.20.09
Time to throw out the supplements? Comments on The New York Times article: “Vitamin Pills: A False Hope?”
Several people have asked us to comment on recent news stories about research showing that taking vitamin pills has little if any health benefit, and in fact may be harmful in certain instances (such as for people with a cancer diagnosis). A representative article in this vein is the New York Times piece “Vitamin Pills: A False Hope?” by Tara Parker-Pope, published Feb. 16, 2009, and accessed by us online at http://www.nytimes.com/2009/02/17/health/17well.html.
Here’s our commentary, which takes its start from a key passage in the article:
NYT: In any event, most major vitamin studies in recent years have focused not on deficiencies but on whether high doses of vitamins can prevent or treat a host of chronic illnesses. While people who eat lots of nutrient-rich fruits and vegetables have long been known to have lower rates of heart disease and cancer, it hasn’t been clear whether ingesting high doses of those same nutrients in pill form results in a similar benefit.
NYBC BLOG: 1. In fact, most of the studies making news are surveys of people with no known vitamin deficiency and no evident health problem. The studies cited generally found that there was no improvement in rates of disease development over time (heart disease and cancers, primarily) for people taking the vitamins, as opposed to those who didn’t. On the other hand, NYBC’s interest has focused on the detection of vitamin deficiencies in people with chronic illnesses such as HIV, and then targeted supplementation and its results. For example, supplementation with Vitamin D (plus calcium) in people that are deficient has been found to have benefit, both for bone health and for reduction of cardiovascular disease risk (and, according to more recent research, for cancer risk as well). The same goes for supplementation with people deficient in minerals; in a well-known study, University of Miami researchers identified selenium deficiency in people with HIV, and also found that supplementing with this mineral improved health in this group. More generally, many vitamin and other nutrient deficiencies have been detected in people with HIV, and there have been many studies showing health benefits from supplementing to counteract these deficiencies. So, in conclusion, we are not terribly surprised if people with no known vitamin deficiencies and no known health problems are found not to gain much, if any, health benefit from taking vitamins–but that’s really a different question from those (many) studies showing that specific deficiencies and their related disease states can often be successfully addressed by supplementation.
2. Regarding vitamins and cancer: we certainly recommend caution here, and have frequently referred people to the Memorial-Sloan Kettering Cancer Center website on complementary medicine for guidance. Studies have indicated that vitamin supplementation (with C, for example) can accelerate certain cancers. However, as the MSKCC website shows, there is wide interest in, and much evidence for, use of certain dietary supplements as adjuncts in cancer therapy. The world of dietary supplements is much bigger than just the short list of vitamins; and research on supplements and cancer is a major topic among projects funded by such sources as the federal government’s National Center for Complementary and Alternative Medicine. Indeed cancer research has focused quite often on the therapeutic potential of botanical sources. The cancer drug paclitaxel, to give just one example, derives from the yew tree; and many traditional botanicals continue to be studied for their anti-cancer properties: turmeric/curcumin, green tea (with its polyphenols), silymarin, astragalus, to name just a few.
3. While the vitamin studies reported in the NYT article are negative, no one disputes the fact that nutrition has an enormous impact on health. In fact, the New York Times also recently ran articles reiterating the substantial health benefits of the “Mediterranean diet” (good fats like olive oil rather than bad fats; fish rather than meat; carbs from beans, peas, lentils; more veggies than meats), which has been associated with lower risk of heart disease and–in a newer area for research–a lower risk of depression and other mental health disorders. So, can the clear health benefits of a particular diet be translated in any useful way to the field of supplements? One obvious “yes” comes in the increased study and use of fish oil/omega-3 fatty acid supplements over the last few decades. Here’s a case in which an individual nutrient within a healthful diet has been isolated and can be usefully delivered as a supplement that bestows health benefits. (Fish oil supplements have a particular advantage over food sources, too: they can be refined to eliminate mercury contamination, a growing concern these days, whether you are eating fresh or canned fish.) We certainly know that it is possible to extract a component from food and use its particular properties to confer a health benefit, while leaving behind some other parts of the food that we don’t want or need. (This is the case with whey protein powders, which leave behind milk fat, but keep the whey protein with its interesting nutritional benefits.)There may also be increasing recognition that effective supplementation can require a wide-spectrum approach. Instead of emphasis on single vitamins, we’ve known for a while that the B vitamins work together and are usually best taken as a complex; or that a complex of carotenoids from vegetable sources is probably better than just a few select samples of these compounds. Of course, we would like to have more research about the particular value conferred by “food-based” supplements such as the popular “green foods.” In short: do choose a good diet to stay healthy, but don’t throw out the supplements, which can also make their contribution to your health and well-being!
02.19.09
Lark Lands: Nutritional approaches to neuropathy, diabetes, and HIV-related fatigue or gastrointestinal problems
Lark Lands, who has written for POZ magazine and for the Canadian AIDS Treatment Information Exchange (CATIE) website, now offers moderately priced e-books that synthesize her knowledge of nutritional therapies for conditions like HIV-related fatigue or gastrointestinal problems, diabetes, and neuropathy. In our experience, she offers clear and practical advice for addressing symptoms and side effects, so we expect these latest examples of her point of view will be worth looking at.
Here’s the link:
02.17.09
Green Tea: Potential Adjunct Therapy for Rheumatoid Arthritis?
The National Center for Complementary and Alternative Medicine, one of the research centers of the federal government’s National Institutes of Health, has posted this summary of a recent study of green tea and rheumatoid arthritis on its website:
Rheumatoid arthritis (RA) is an autoimmune disease that affects more than 2.1 million Americans. It is characterized by joint pain, stiffness, inflammation, swelling, and sometimes joint destruction. Nonsteroidal anti-inflammatory drugs are the standard treatment for RA, but their prolonged use is associated with adverse effects and discomfort. Natural plant alternatives like green tea are being investigated for the management of RA. Green tea is the most widely consumed beverage in the world, and its polyphenols (substances rich in antioxidants) possess anti-inflammatory properties.
NCCAM-funded investigators at the University of Maryland and Rutgers University examined the effects of green tea polyphenols on RA by using an animal model in rats. The animals consumed green tea in their drinking water (controls drank water only) for 1 to 3 weeks before being injected with heat-killed Mycobacterium tuberculosis H37Ra to induce arthritis. The researchers found that green tea significantly reduced the severity of arthritis.
The researchers suggest that green tea affects arthritis by causing changes in various arthritis-related immune responses—it suppresses both cytokine IL-17 (an inflammatory substance) and antibodies to Bhsp65 (a disease-related antigen), and increases cytokine IL-10 (an anti-inflammatory substance). Therefore, they recommend that green tea be further explored as a dietary therapy for use together with conventional treatment for managing RA.
References and further information from NCCAM at:
http://nccam.nih.gov/research/results/spotlight/120808.htm
See also the NYBC entry on Green Tea (Jarrow).
Other studies of green tea are reported on this blog; see “Green Tea” category in the sidebar.
02.11.09
Sublingual Vitamin B12 for better absorption
For those with serious Vitamin B12 deficiency, injections or sublingual tablets (tablets that dissolve under the tongue) are often recommended.
This recommendation may be especially pertinent for people with HIV who experience peripheral neuropathy. But B12 is crucial for many systems in the body, and the use of sublingual tablets may be advised in a number of cases.
Here’s a Canadian AIDS Treatment Information Exchange Info Sheet on Vitamin B deficiency in people with HIV; it presents some of the rationales for use, and also underlines the importance of getting an effective dose through injection or sublingual tabs: CATIE INFO SHEET ON HIV and VITAMIN B12
NYBC, like its predecesor DAAIR, stocks B-12 as Methylcobalamin (Jarrow). These are chewable tablets; or may be dissolved under the tongue. The methylcobalamin form is generally acknowledged to be well-absorbed (=”bioavailable”).
02.05.09
High Frequency of Vitamin D Deficiency in People with HIV
A number of reports in recent years have suggested an increased prevalence of osteopenia and osteoporosis (moderate and severe bone loss) in HIV-infected patients. In 2008, moreover, a study in the Journal of Clinical Endocrinology & Metabolism reported a higher rate of fractures in HIV-infected individuals compared with uninfected individuals. So there is reason for concern that osteoporosis and osteoporotic fractures will become major health problems for people with HIV as they age.
Here, we’re reporting on another study, released at the start of 2009, which fills in more pieces of information about bone health in people with HIV–and also provides guidance on supplementation strategies that could counteract bone loss and increased bone fracture rates associated with HIV. This research looked at fairly healthy (“ambulatory”) people with HIV visiting a Boston clinic in mid-winter and early spring months, and found a high frequency of vitamin D deficiency. Further tests linked this deficiency to a diminished ability to absorb and use calcium, the central ingredient in bone mass.
Based on their study, the investigators suggested that many people with HIV could benefit from daily vitamin D intake of at least 700-800 IU taken with 1200-1500mg of calcium, especially during the winter months, when the body does not have the opportunity to produce Vitamin D from exposure to sunlight.
Our conclusion: studies are now filling in the details that allow us to conclude that osteoporosis and osteoporosis-related fractures may become an increasingly important health concern for people with HIV as they age. However, there is also growing evidence that supplementing with Vitamin D and calcium can reduce this risk to bone health. It’s therefore important for people with HIV to check their multivitamin to see if they are getting appropriate levels of these two nutrients, or add a specific Vitamin D – Calcium supplement to their diet.
NOTE: NYBC stocks Vitamin D3 (the form most readily used by the body) and Calcium Blend (a food-based vegetarian supplement which includes Vitamin D3). Also available: Bone Up (Jarrow), a supplement containing calcium, Vitamin D and other components specifically for bone health.
Reference: M. Rodriguez, B. Daniels, S. Gunawardene, and G.K. Robbins. High Frequency of Vitamin D Deficiency in Ambulatory HIV-Positive Patients. AIDS RESEARCH AND HUMAN RETROVIRUSES, Vol 25, 1, 2009.
02.03.09
Review article: “Nutritional therapies for mental disorders” (2008)
Shaheen E Lakhan and Karen F Vieira. Nutritional therapies for mental disorders. Nutrition Journal 2008, 7:2doi:10.1186/1475-2891-7-2
This well-documented article provides a state-of-the-art review of nutritional therapies or nutritional supplementation for some of the most prevalent disabling mental disorders. Here’s an excerpt from the introduction of the article, which gives an idea of its scope and the significance of its topic:
Currently, approximately 1 in 4 adult Americans have been diagnosed with a mental disorder, which translates into about 58 million affected people. Though the incidence of mental disorders is higher in America than in other countries, a World Health Organization study of 14 countries reported a worldwide prevalence of mental disorders between 4.3 percent and 26.4 percent. In addition, mental disorders are among the leading causes for disability in the US as well as other countries. [...] [T]he four most common mental disorders that cause disabilities are major depression, bipolar disorder, schizophrenia, and obsessive compulsive disorder (OCD).
Typically, most of these disorders are treated with prescription drugs, but many of these prescribed drugs cause unwanted side effects. For example, lithium is usually prescribed for bipolar disorder, but the high doses of lithium that are normally prescribed cause side effects that include: a dulled personality, reduced emotions, memory loss, tremors, or weight gain. These side effects can be so severe and unpleasant that many patients become noncompliant and, in cases of severe drug toxicity, the situation can become life threatening.
Researchers have observed that the prevalence of mental health disorders has increased in developed countries in correlation with the deterioration of the Western diet. Previous research has shown nutritional deficiencies that correlate with some mental disorders. The most common nutritional deficiencies seen in mental disorder patients are of omega-3 fatty acids, B vitamins, minerals, and amino acids that are precursors to neurotransmitters. Compelling population studies link high fish consumption to a low incidence of mental disorders; this lower incidence rate has proven to be a direct result of omega-3 fatty acid intake. One to two grams of omega-3 fatty acids taken daily is the generally accepted dose for healthy individuals, but for patients with mental disorders, up to 9.6 g has been shown to be safe and efficacious. Western diets are usually also lacking in fruits and vegetables, which further contributes to vitamin and mineral deficiencies.
It’s refreshing to see a respected publisher of scientific journals such as Springer giving a place to this kind of review. By pulling together the best of recent research on nutritional therapies for mental health (there are 107 references for this article, almost all from the last two decades), the authors provide support to a very useful approach that has been unfortunately overshadowed by over-reliance on prescription medications. We hope this publication, together with others like it, will help educate both healthcare providers and healthcare consumers!
You can read the complete article at
02.02.09
Calcium carbonate for protease inhibitor-related diarrhea
Calcium is best-known as a supplement to support bone health, but it also has a long history of use to control diarrhea, especially protease inhibitor-related diarrhea, in people with HIV.
Below are a couple of recent Canadian studies that tend to re-affirm the effectiveness of this widely used strategy. See also the NYBC entry on Digestive Maintenance, which includes two types of Calcium supplement.
Turner MJ, Angel JB, Woodend K, Giguère P. The efficacy of calcium carbonate in the treatment of protease inhibitor-induced persistent diarrhea in HIV-infected patients. HIV Clin Trials. 2004 Jan-Feb;5(1):19-24. Pharmacy Department, The Ottawa Hospital, Ontario, Canada.
BACKGROUND: Although some evidence exists to support the practice of using calcium carbonate to treat nelfinavir-induced diarrhea, there is a lack of data supporting the role of calcium in diarrhea induced by other protease inhibitors (PIs). PURPOSE: The objective of this prospective open-label study is to evaluate the efficacy of calcium carbonate in the treatment of PI-induced persistent diarrhea in HIV-infected patients. METHOD: Along with dietary advice, patients were asked to take oral calcium carbonate 500 mg twice daily for 2 weeks. Visual Analog Scale (VAS) and the National Cancer Institute of Canada (NCIC) scale were used to assess the severity of diarrhea. Data were analyzed using paired t tests to test for differences in VAS and NCIC scores between baseline and 14 days. Pearson correlation was used to explore the relationships between change in diarrhea and patient baseline factors. RESULTS: At day 0, the mean VAS +/- standard deviation was 6.6 +/- 2.1 and decreased to 5.3 +/- 1.9 (p=.01) after 14 days. At day 0, the mean NCIC score was 1.9 +/- 0.8 and decreased to 1.2 +/- 0.9 (p=.005) after 14 days. No baseline patient factors predicted change in NCIC or VAS grade. CONCLUSION: Calcium carbonate is associated with a reduction of diarrhea in individuals with diarrhea induced by PI.
**
Rachlis A, Gill J, Baril JG, LeBlanc RP, Trottier B, MacLeod J, Walmsley S, Van der Vliet W, Belsky G, Burgoyne R. Effectiveness of step-wise intervention plan for managing nelfinavir-associated diarrhea: a pilot study. HIV Clin Trials. 2005 Jul-Aug;6(4):203-12. Sunnybrook and Women’s College Health Sciences Centre, University of Toronto, Ontario, Canada. a.rachlis@utoronto.ca
PURPOSE: Pilot study to evaluate the effectiveness of a step-wise diarrhea management strategy for nelfinavir-associated diarrhea. METHOD: HIV-infected adults (CD4 count > 100 cells/mm3, and no evidence of enteric pathogens) developing symptoms of diarrhea after initiation of nelfinavir for a duration of > or = 1 month were enrolled into this 9-week prospective pilot study. Step-wise interventions, reviewed and adjusted additively at 2-week intervals, included nutritional counseling (+/- lactase and/or psyllium), calcium carbonate, and loperamide. Outcome measure included stool-form consistency, bowel movement frequency, and incidents of associated morbidity (urgency, incontinence) daily. Patient quality of life was also assessed. RESULTS: Eighteen patients completed the study. Mean daily bowel movement frequency decreased by 32%, from 2.98 to 2.03 (p = .005). Mean daily stool form shifted from a rating of 4.24 to 2.37 (p = .0001), representing a shift to firmer stools. Period prevalence of incontinence (28%) and urgency (33%) decreased to 6% each, respectively. Quality of life ratings relating to gastrointestinal disturbance and overall physical/psychosocial function were improved. CONCLUSION: The results of this pilot study demonstrated that a step-wise intensified approach may be successful in managing nelfinavir-associated diarrhea and will need to be validated in a larger scale, randomized controlled trial.
