HIV and Aging: Living Long and Living Well

By 2015, more than 50% of the United States HIV population will be over 50. There are approximately 120,750 people now living with HIV/AIDS in NYC; 43% are over age 50, 75% are over age 40. Over 30% are co-infected with hepatitis.

What does the future hold for people with HIV and HIV/HCV as they get older?

These statistics and this question furnished the starting point for the New York Buyers’ Club March 28 event HIV and Aging: Living Long and Living Well, presented by Stephen Karpiak, PhD, of the AIDS Community Research Initiative of America (ACRIA).

Dr. Karpiak’s background uniquely positions him to paint the full picture behind the bare statistics, and to provide expert guidance through the complex healthcare challenges faced by the growing population of older people with HIV. After two decades as a researcher at Columbia University’s Medical School, Dr. Karpiak moved to Arizona, where he directed AIDS service organizations through the 1990s, including AIDS Project Arizona (which offered a supplements buyers’ club similar to NYBC’s). In 2002, back in NYC, he joined ACRIA as Assistant Director of Research, and was the lead investigator for the agency’s landmark 2006 study, Research on Older Adults with HIV. This report, the first in-depth look at the subject, surveyed 1,000 older HIV-positive New Yorkers on a host of issues, including health status, stigma, depression, social networks, spirituality, sexual behavior, and substance abuse.

Why are there more and more older people with HIV? The first and principal answer is very good news: HIV meds (HAART), introduced more than 20 years ago, have increased survival dramatically. Secondly, a smaller but still significant reason: older people are becoming infected with HIV, including through sexual transmission. (Older people do have sex, though sometimes healthcare providers don’t seem to acknowledge this reality.)

As Dr. Karpiak noted, HAART prevents the collapse of the immune system, and so it serves its main purpose, to preserve and extend life. And yet, as he reminded the audience, HIV infection initiates damaging inflammatory responses in the body that continue even when viral load is greatly suppressed. These inflammatory responses, together with side effects of the HIV meds, give rise to many health challenges as the years pass. In people with HIV on HAART, research over longer time periods has found higher than expected rates of cardiovascular disease, liver disease, kidney disease, bone loss (osteoporosis), some cancers, and neurological conditions like neuropathy.

That brings us to “multi-morbidity management”—a term we weren’t enthused about at first, since it sounded more like medical-speak than the plain talk our NYBC event had promised. But Dr. Karpiak gave us a simple definition: dealing with three or more chronic conditions at the same time (and HIV counts as one). He then made the case that this is a critical concept to grasp if older people with HIV are going to get optimal care. Multi-morbidity management, he explained, is a well-accepted healthcare concept in geriatric medicine, which recognizes that older people may have several conditions and will benefit from a holistic approach in order to best manage their health. Treating one condition at a time, without reference to other co-existing conditions, often doesn’t work, and sometimes leads to disastrously conflicting treatments.

And here’s where Dr. Karpiak warned about “polypharmacy”–another medical term worth knowing. “Polypharmacy” can be defined as using more than five drugs at a time. Frequently, it comes about when healthcare provider(s) add more and more pills to treat a number of conditions. But this approach can backfire, because, as a rule of thumb, for every medication added to a regimen, there’s a 10% increase in adverse reactions. That’s why adding more and more drugs to treat evolving conditions may be a poor approach to actually staying well.

In closing, Dr. Karpiak focused especially on a finding from ACRIA’s 2006 study: the most prevalent condition for older people with HIV, aside from HIV itself, was depression. Over two-thirds of those surveyed had moderate to severe depression. Yet while depression can have serious conse-quences–such as threatening adherence to HIV meds–it has remained greatly under-treated. It may seem an obvious truth, but as Dr. Karpiak underlined, psychosocial needs and how they’re met will play a big role in the health of people with HIV as they age. What social and community supports are available becomes a big medical question, and how healthcare providers and service organizations respond to it can make for longer, healthier lives for people with HIV.

And now we come back to NYBC’s contribution to the discussion on HIV and Aging. While NYBC doesn’t keep track of such information in a formal way, we do recognize that quite a few of our members have been using supplements since the days of our predecessor organization DAAIR–going back 20 years now. That’s a lot of accumulated knowledge about managing symptoms and side effects among people with HIV! To accompany the March 28 presentation, our Treatment Director George Carter drew up a pocket guide to complementary and alternative approaches: HIV and Aging – Managing and Navigating. Partly derived from his long experience, and partly drawn from a 2012 Canadian report, the guide ranges over those kinds of “co-morbidities” that Dr. Karpiak spoke of, including cardiovascular, liver, kidney, bone, and mental health conditions. Interventions or management strategies include supplements, but also diet and exercise recommendations, as well as psychosocial supports (counseling, support groups, meditation, and activism).

NYBC has also updated several info sheets from its website and blog, offering these as a way to address some of the most common healthcare issues facing people with HIV as they get older: cardiovascular topics; :digestive health; NYBC’s MAC-Pack (a close equivalent to K-PAX®); key antioxidants NAC and ALA and their potential to counter inflammatory responses; and supplement alternatives to anti-anxiety prescription drugs. These info sheets, together with the HIV and Aging – Managing and Navigating pocket guide, are available on the NYBC website and blog.

We hope that our HIV and Aging: Living Long and Living Well event has been useful to all. Special thanks to our audience on March 28, many of whom brought excellent questions to the session. Now let’s continue the conversation…

To your health,

New York Buyers’ Club

NYBC_March282013

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Alpha lipoic acid for diabetic sensory neuropathy

A recent review article suggested that a dose of 600 mg alpha lipoic acid (ALA) daily administered for up to 5 weeks could offer benefits in symptoms of diabetic sensory neuropathy without significant side effects. This review also notes that ALA is already approved for treatment of neuropathy in Germany. Furthermore, it seems obviously a better choice than the opioids often prescribed for diabetic neuropathy pain, as these induce addiction.

For more on alpha lipoic acid, see the NYBC entries:
Jarrow ALA sustained and Montiff ALA. NYBC also stocks Jarrow ALA plus Biotin; biotin is a B vitamin that has also been recommended for diabetes.

REFERENCE:

McIlduff CE, Rutkove SB, Critical appraisal of the use of alpha lipoic acid (thioctic acid) in the treatment of symptomatic diabetic polyneuropathy. Therapeutics and Clinical Risk Management. Sept. 2011 Volume 2011:7 Pages 377 – 385

NYBC’s ThiolNAC – Antioxidant Supplement

ThiolNAC at NYBC

NYBC’s specially manufactured antioxidant supplement, ThiolNAC, is again in stock at the nonprofit co-op. Below is the product description for this combination supplement, which is available only through NYBC, and which provides a key part of NYBC’s MAC-Pack, our LOW COST alternative to K-PAX:

ThiolNAC (NYBC) Each bottle, 90 tablets, sustained release formula. Each tablet contains 500 mg of NAC and 134 mg of alpha lipoic acid. As part of the MAC Pack, three per day provide the equivalent dose as used in the original neuropathy study published in the journal AIDS: 1500 mg of NAC and 402 mg of alpha lipoic. This is an excellent formula for those suffering from liver inflammation. It is also extremely convenient for many PWHIVs who take both NAC and Lipoic Acid since this 2-in-1 combination eliminates some pills while providing the same, generally accepted dosages. Suggested use is 2-3 tablets daily with meal or as directed. Reduce dose if headaches occur.

Note: This version of NYBC’s ThiolNAC intentionally decreases the alpha lipoic acid amounts per tablet from our original formula’s 200mg/tab to the present formula’s 134mg/tab. This change brings us precisely in line with the dosage studied in Jon Kaiser’s study, and also responds to a concern raised by our colleague Lark Lands regarding higher dose alpha lipoic and hypothyroidism.

Neuropathy pain and HIV: supplement recommendations

You may have read reports in late February 2012 about the FDA’s skeptic ism about a patch called Qutenza, which had been tested for relief of neuropathy pain in people with HIV. Following a meeting to review the evidence, an FDA panel concluded that Qutenza, whose active ingredient is a synthetic form of capsaicin (the compound that makes chili peppers hot) was not effective for HIV-related neuropathy pain.

The FDA’s finding on Qutenza reminds us again that neuropathy (generally, pain or tingling in the extremities) continues to be one of the most troublesome effects of HIV/AIDS and/or its treatment—and one of the most difficult to manage. According to a survey report in 2010, for example, more than one third of those on combination antiretroviral therapy for HIV do experience neuropathy, leading to lower quality of life and often disability. So, it may be worthwhile to repeat some of NYBC’s recommendations on this topic:

Peripheral neuropathy: “nukes” (nucleoside reverse transcriptase inhibitors) such mas ddI (Videx), and d4T (stavudine/ Zerit) – and Indinavir, T20, and even 3TC (Epivir)may all cause this feeling of pins and needles or numbness to toes and fingers. It can travel up the legs and become debilitating. HIV, diabetes, alcohol abuse, and vitamin deficiencies can all be causes of peripheral neuropathy. Supplements that are “good for your nerves” and that have the most robust data include acetylcarnitine (1-3 grams/ day, quite well studied for peripheral neuropathy) and alpha lipoic acid (200-600 mg/day). Other agents that can help are Vitamin B12, biotin, lecithin, magnesium, borage oil, evening primrose oil, choline and inositol.

See the NYBC website for more details about these supplements:
http://nybcsecure.org/

Alpha Lipoic Acid and Type 2 Diabetes

There is growing evidence that Alpha Lipoic Acid (ALA) has beneficial effects on the treatment of Type 2 Diabetes and some of its complications. Its wide-ranging benefits for diabetes include improved glycemic control, improved insulin sensitivity, reduction of oxidative stress, and reduction of neuropathy.

A recent review of ALA for diabetes concluded that the supplement’s side effects were generally limited, and found that it was generally safe for use even by those with impaired kidney or liver function. (NYBC adds only a caution about a potential thyroid issue, especially for those taking higher doses of ALA.)

See the NYBC entry

Alpha Lipoic with Biotin

Reference:

Poh Z, Goh KP. A current update on the use of alpha lipoic Acid in the management of type 2 diabetes mellitus. Endocr Metab Immune Disord Drug Targets. 2009 Dec;9(4):392-398.

NYBC’s MAC-Pack on the “Ask The Experts” forum, thebody.com

We were glad to see a recent Q&A on the “Ask the Experts” forum of thebody.com, which is one of the leading online sources of information for people with HIV. The question concerned NYBC’s MAC-Pack, our low-cost, close equivalent to K-PAX, a multivitamin/antioxidant combination which has been shown in research to raise CD4 counts, and which is available thru some — but not all–formularies in some — but not all — states.

For more information, see NYBC’s entry

MAC-Pack
Here’s the exchange:

QUESTION: macpac
Jul 5, 2011
are you familiar with the co. NYBC and their MACPAC-combination multivitamin & antioxidant program sells for 65 dollars and they compare to KPAC for 1/2 the cost..don’t want to throw money away on useless vitamins or vitamins that are sub-par or not tested

ANSWER: Response from Mr. Vergel

Supplement quality is always an important issue. One available resource is http://www.consumerlab.com although they are a for-profit company. It would be preferable if there were a government agency that routinely tested supplements and published the results!
It will always be a bit of a crapshoot, but the good news is the majority of supplements tested by them either pass and those that do fail often do for relatively minor reasons (though some do spectacularly).
According to Jared Becker and George Carter from the New York Buyers Club, the brands used in NYBC’s MAC Pack come from companies as reputable as K-PAX and with longer histories. NYBC has assessed Jarrow, Douglas Labs and Montiff, the providers used to make the Mac Pack. A few years ago, NYBC sent Montiff’s acetylcarnitine for testing and it came back fine. NYBC also uses consumerlab’s reports to verify quality of our big suppliers like Jarrow and Douglas.

Nelson Vergel

Entry posted at: http://www.thebody.com/Forums/AIDS/Nutrition/Q216051.html?ic=700101

Supplements for the Brain (and Nerves)

“For Your Peace of Mind…”

Recent research on supplements for memory, cognition and other neurological functions
You may remember (we hope you remember!) the Scarecrow’s petition to the Wizard of Oz for a brain. Be advised–we at NYBC do not stock new brains, so don’t come to us with that request.

However, we do follow the sometimes startling new research on supplements, brain function and related neurological issues. In this department, there’s special cause for concern for people with HIV. According to a Canadian study released in 2010, in a group of 1615 people receiving treatment for HIV during the decade 1998-2008, one fourth had neurological problems, including memory loss, cognitive impairment and peripheral neuropathy. Of course being worried about brain function–and neurological function in general–is not unique to people with HIV. As people age, they are more likely to experience memory loss or forms of dementia such as Alzheimer’s. And the nerve condition called peripheral neuropathy (pain, tingling in the feet and hands) is found not just in people with HIV, but also among the growing population with Type 2 diabetes.

Now, on to what we see as some of the most valuable recent findings about supplements and brain or neurological function:

B vitamins can be considered a foundation because they are needed in so many processes essential to the brain’s operation, from energy supply and healthy blood flow, to the formation of neurotransmitters (=chemical messengers of neurologic information from one cell to another). Furthermore, there is evidence that several groups of people, including those over 60 and those with HIV, have a greater risk for Vitamin B deficiencies. So supplementing with a B complex vitamin is a sensible start to cognitive health. More specifically, there is good research linking deficiency of vitamins B12 and B6 to mood disorders like depression—and depression earlier in life is associated with higher risk of dementia in later life. Last, there is also some evidence that B vitamins may reduce stroke risk in older people.

Omega-3 fatty acids (fish oil) support cognitive health in a variety of ways. In 2008, UCLA researchers reported on a lab study showing that the omega-3 fatty acid DHA, together with exercise, improved cognitive function. This caught our attention, because there is wide agreement that regular exercise strongly supports brain function as we age, and here the suggestion is that omega-3 fatty acids multiply that known benefit. A diet rich in omega-3 fatty acids/fish oil has also been linked to lower risk of depression—another plus. And still more: recent research found that omega-3 fatty acids block the development of retinopathy, a chief cause of blindness as we age. (The retina of the eye is actually part of the brain–it is full of nerve cells essential for vision.) All in all, the neurological benefits of omega-3 fatty acids seem both wide-ranging and quite convincing, so it’s high on our recommended list.

The amino acid acetylcarnitine has shown benefit for brain function in a number of studies with humans. In the last decade, acetylcarnitine has also been investigated for peripheral neuropathy in people with HIV. (Some recommend using it with evening primrose oil and Vitamin C.) A 2008 study found that acetylcarnitine influences a chemical process in the brain that triggers Alzheimer’s, so researchers are continuing to puzzle out how this supplement produces its neurological benefits.

Antioxidants. There’s much suggestive research about how antioxidants counter destructive oxidative processes in the brain, thus blocking memory loss and cognitive decline. For example, a 2003 report found that the antioxidant combination alpha lipoic acid and NAC reversed memory loss in aged laboratory mice. And there’s also been a lot of attention to the combination acetylcarnitine and alpha lipoic acid for memory impairment. Furthermore, other antioxidants such as curcumin are under study for their potential to fight the processes that lead to declining brain function.

Acetylcholine. The first neurotransmitter to be identified, acetylcholine is closely associated with memory, with lower levels linked to memory loss. NYBC currently stocks two combination supplements that support acetylcholine levels in the brain, while also providing other nutrients for neurological function: Neuro Optimizer (Jarrow), which includes acetylcholine enhancers, acetylcarnitine, and alpha lipoic acid; and Think Clearly (SuperNutrition), which includes B vitamins, as well as acetylcholine enhancers and a botanical traditionally used for cognitive support, ginkgo biloba.

Resveratrol. In the past decade, there has been intense scientific interest in this compound, most famously found in red wine. While some research ventures have hoped to find in resveratrol a life-extending supplement (a capacity demonstrated in animal studies), others have focused on its therapeutic value for conditions like diabetes or cognitive decline. For example, Cornell researchers reported in 2009 that resveratrol reduced the kind of plaque formation in animal brains that causes Alzheimer’s. And a year later another lab investigation, this one at Johns Hopkins, found that a moderate dose of the compound protected animal brains from stroke damage.

Ginkgo biloba, a botanical derived from Earth’s most ancient tree species, has been widely used for cognitive function. In the late 1990s, two reviews of dozens of ginkgo studies concluded that it could improve symptoms of dementia. However, a long-term trial of ginkgo published in the Journal of the American Medical Association in 2008 found that the supplement did not prevent development of dementia in a group of more than 3000 older people who had normal cognitive function at the start of the research. One possible conclusion: ginkgo may help symptoms of cognitive decline, but doesn’t address underlying causes.

NYBC’s RECOMMENDATIONS: A B complex supplement (like Jarrow’s B-right) and fish oil (like Jarrow’s Max DHA) are foundations for maintaining cognitive health, especially important for people with HIV or people over 60. There is some evidence for acetylcarnitine, alpha lipoic and acetylcholine supplementation for memory impairment and possibly for cognitive decline. Acetylcarnitine and other supplements can be used to address peripheral neuropathy. And stay tuned for emerging research on preserving brain function with compounds like resveratrol, NAC and curcumin.