Supplements for Diarrhea and Malabsorption

We’re reprinting below the NYBC recommendations
for supplements that address the common gastrointestinal
problems of people with HIV:

Diarrhea. This is one of
the most common side effects of
antiretroviral drugs–especially protease
inhibitors. When it occurs, make
sure to drink plenty of (healthy) fluids
to replace electrolytes (potassium,
sodium, and magnesium ions) and
prevent dehydration. Avoid sugary
and/or caffeinated beverages.
One of the simplest remedies: bananas!
Adding a yogurt with active
cultures to your regular diet can also
improve diarrhea. In addition to adding
beneficial flora to your gastrointestinal
tract, yogurt is nutritionally
rich in protein, calcium, riboflavin,
vitamin B6 and vitamin B12.

However, for some, dietary changes may
not be enough to control the diarrhea
Supplements to consider in treating
diarrhea associated with protease
inhibitors include calcium, and glutamine
(up to 20-40 grams daily for
diarrhea while it persists). There are
some clinical data to support these
interventions. A note of caution: calcium
carbonate works fine but should
be avoided if you are using atazanavir
[Reyataz].

If diarrhea is associated with the use
of antibiotics, go probiotic! Use acidophilus,
bifidus or Saccharomyces
boulardii
(Florastor) to control C.
difficile (a problem frequently encountered
with antibiotic use) and to improve gut function.
Use of digestive enzymes may also help to improve
digestion (e.g., lipase, protease, amylase, and
lactase).

Malabsorption is the difficulty in digesting or
absorbing nutrients from food. It’s a widespread
problem among HIVers, and a serious
one at that. HIV disease damages the
guts, where it is estimated that 80%
of the disease “lives,” hindering the
digestive tract’s ability to absorb nutrients
(or meds). Additionally, many
HIVers actually have too little acid
in their stomachs – a little-discussed
condition. This can cause the sphincter
at the opening of the stomach to
fail to close properly, resulting in
GERD: gastro-esophageal reflux disorder.
In general, gut function can be
improved with probiotics such as
acidophilus and bifidus, as well as
2-5 grams of glutamine, taken daily.
Further, digestive enzymes that help
break down fats, carbs and proteins
may be useful in promoting better
absorption. Again, a good diet and
a potent multi are important starting
points!

See the NYBC entries for more detailed
recommendations regarding these supplements:

Glutamine Powder:
http://nybcsecure.org/product_info.php?cPath=49&products_id=128
or Glutamine Caps:
http://nybcsecure.org/product_info.php?cPath=49&products_id=127

Douglas Vegetarian Enzymes:
http://nybcsecure.org/product_info.php?cPath=49&products_id=264
Jarro-Zymes Vegetarian Enzymes:
http://nybcsecure.org/product_info.php?cPath=49&products_id=335

Ultra Jarro-Dophilus (probiotic):
http://nybcsecure.org/product_info.php?cPath=27&products_id=354
Jarrodophilus EPS (No refrigeration needed):
http://nybcsecure.org/product_info.php?cPath=27&products_id=199
Saccharomyces boulardii (Florastor):
http://nybcsecure.org/product_info.php?products_id=217

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NYBC’s Quick Guide to Gastrointestinal Health

A number of NYBC members and visitors to our website and blog have asked us to reprint the NYBC “Quick Guide to Gastrointestinal Health,” which first appeared in the Winter 2009 issue of our free newsletter THE SUPPLEMENT:

NYBC’s Quick Guide to Gastrointestinal Health

Gastrointestinal or gut health is basic to overall health, whether you’re talking about how well you feel on a daily basis (nausea, cramps, diarrhea, etc. being among our least favorite experiences), or the importance of properly absorbing food that you eat and thereby supplying your body with the nutrients it needs to stay healthy over the long term.

Gastrointestinal health can also be a complicated issue, since gut disturbances may stem from many different causes, whether it’s a bug picked up from poor food handling practices, a side effect of medications, or one of the symptoms of an underlying disease or infection (such as HIV) that requires treatment in itself. Identifying the root cause or causes of gastrointestinal problems can be a major challenge, and of course we urge you to work with your healthcare provider to sort that question out, especially if your condition lingers, becomes acute, or has an impact on your ability to go about your daily life.

Below we present various tips, tricks, news and research notes, all designed to help you maintain good gastrointestinal health, or find help when things are not going so well in your digestive tract.

Probiotics. These are “friendly” microorganisms that can re-balance the ecology of your gut. Probiotics are well-known for their benefit to digestive health, and especially for their ability to resolve some types of diarrhea. Here are the major types stocked by NYBC: bifidus (as Bifidus Balance/Jarrow); lactobacillus/bifidus (as Jarrodophilus/Jarrow—needs refrigeration); lactobacillus/bifidus (as Jarrodophilus EPS–needs no refrigeration); and Saccharomyces boulardii (as Florastor from Biocodex—needs no refrigeration).
Some NYBC members find that using Jarrodophilus every other day keeps diarrhea away. (And it’s actually cheaper than getting the probiotics from yogurt—though admittedly not quite so tasty or nutritious.) Another approach: try the green foods supplement Pro Greens (Nutricology), which has a rich variety of nutrients, but also includes a substantial lactobacillus/bifidus component. The BioCodex product Florastor, meanwhile, is most often used for antibiotic-associated diarrhea or to avoid “traveler’s diarrhea” (when started in advance of the trip).

Research note, as reported last year by John James in the online AIDS Treatment News Daily Alerts. The note deals with C. difficile, a diarrhea-producing infection that’s on the rise, and is often a lingering byproduct of antibiotic treatment: “A recent meta-analysis of 31 studies compiled and published in the American Journal of Gastroenterology concluded that S. boulardii is the only probiotic that is effective in fighting recurrent C. diff-associated disease. […] ‘Because Florastor (S. boulardii) is a yeast and not a bacteria, it is not killed by the strong antibiotics that are being used to kill the C. diff bacteria, so it survives in the digestive tract,’ says [researcher] Dr. Raymond. ‘When the ‘baby’ C. diff emerge from their spores, they are greeted by a well-colonized gut, rather than an empty playground.’”

Glutamine and other supplements to prevent diarrhea and maintain body weight. In the era of antiretroviral therapy, weight loss has become less of a problem for people with HIV. Yet maintaining muscle mass over time remains a big concern, and one key to that is controlling diarrhea, which deprives the body of needed protein and other essential nutrients.

One frequently used remedy for diarrhea is the amino acid glutamine. It has been studied for leaky gut syndrome, which results when intestinal tissues are damaged, and also has a long history of application to maldigestion in people with HIV. Anecdotally, people with protease-inhibitor diarrhea find relief using 30-40 grams per day. Start with about 15 grams per day and increase the dose until the diarrhea is controlled. A daily maintenance dose is about five grams a day. Note that glutamine is best taken in three daily doses.

Research note: A well-designed study published in the journal Nutrition found that a glutamine-antioxidant regimen was effective at helping HIV+ people with weight loss to regain body weight. The regimen included glutamine (40 g per day), along with vitamin C (800 mg), vitamin E (500 IU), beta-carotene (27,000 IU), selenium (280 mcg), and N-acetylcysteine (2,400 mg). People who took the supplements showed significant weight gain in 12 weeks, while participants taking a placebo did not.

Other supplements have also been used to counteract malabsorption and diarrhea associated with HIV and/or HIV medications:

Calcium: two Canadian studies from 2004 and 2005 re-affirm the thinking that calcium carbonate can be useful in controlling protease inhibitor-related diarrhea. Calcium supplements have long been used for this purpose by buyers’ club members; see the recommendations under “Digestive Maintenance” on the NYBC website for details.

Soluble fiber such as apple pectin, oat bran, and flax seed. For some people, soluble fiber can help food stay in the digestive tract for longer periods of time, increasing the amount of nutrients that are absorbed, and lessening bowel frequency.

Traditional botanicals/remedies for gastrointestinal health. NYBC stocks two formulas produced by the well-regarded California-based developers of herbals, Health Concerns and Pacific BioLogic. Both formulas are derived from traditional schools of herbal medicine (Chinese or Tibetan), but are also informed by modern clinical practice. Here are the indications for use supplied by the manufacturers:

Quiet Digestion (Health Concerns). Used to reduce gastric distress including pain, cramping, nausea, vomiting, diarrhea, regurgitation, poor appetite; addresses viral or bacterial gastroenteritis as well as motion sickness, hangover and jet lag effects.

GI Tract: Gastro Regulator (formerly Digest Ease) from Pacific BioLogic. Derived from a Tibetan medicine formula, it is designed to help the function of the gastrointestinal tract, helping to optimize the course of digestion and colonic function, particularly problems arising from bad dietary habits. There may be a brief period of diarrhea or constipation at the beginning of using this product.

Recently an NYBC member called our attention to Mastic Gum, a resin traditionally used in the Eastern Mediterranean as a remedy for heartburn, and generally to protect the stomach and duodenum. Now there’s intriguing new research supporting use of mastic for gastrointestinal health and perhaps additional purposes as well:

1. A study published in 2007 found evidence that mastic could help prevent or manage prostate cancer. This prostate-protective effect may be achieved via an inhibition of nF-KB–interestingly, that’s a cellular protein that HIV also hijacks to help produce more of itself.

2. Another recent study looked at use of 2.22 grams of mastic/day among patients with Crohn’s disease (a chronic, debilitating bowel disorder). Not only did this dosage help in this small pilot study, but two markers of inflammation were significantly reduced: interleukin-6 and C-reactive protein. Again, it’s of interest that both markers are also often elevated in HIV disease.

TheBody.com booklet: “The HIVer’s Guide to Coping with Diarrhea & Other Gut Side Effects.” NYBC recommends this thorough and easy-to-read booklet, which has been reviewed by HIV specialist physicians, and also includes case studies of people with HIV who have worked through some typical gastrointestinal problems. It can be read online, or ordered from thebody.com at http://www.thebody.com/content/art13137.html.
Here’s a capsule summary of the 29-page booklet:

Gastrointestinal or gut problems–diarrhea, nausea, indigestion, gas, loss of appetite–are very common for people with HIV, with consequences ranging from temporary to very serious. This booklet takes you through the common causes: HIV meds, other meds or supplements, the effects of HIV itself, your diet, psychological triggers, or other health problems (such as parasites). It then sorts through some of the most used remedies, including over-the-counter drugs, supplements, prescription meds, or changing your diet or your HIV drug regimen.

For further information, please also see individual product entries in the “Digestive Maintenance” section of the NYBC catalog. In addition to the items mentioned above in our “Quick Guide,” you’ll also find here our recommendations in the category of digestive enzymes:

DIGESTIVE MAINTENANCE

Bromelain: a digestive enzyme derived from pineapple

Bromelain, an extract from pineapple fruit and stems, is a “proteolytic enzyme,” meaning that it helps in the digestion of proteins (not fats or sugars).

We were interested to read this recent study reported about Bromelain
used to treat a rash called “pityriasis lichenoides chronica,” which has been associated with HIV and Epstein-Barr:

Massimiliano R, Pietro R, Paolo S, Sara P, Michele F. Role of bromelain in the treatment of patients with pityriasis lichenoides chronica. J Dermatolog Treat. 2007;18(4):219-22.

OBJECTIVES: Pityriasis lichenoides chronica (PLC) is a skin disease of unknown etiology. Uncertainty about the etiopathogenesis of this skin disease is the reason for the unpredictable and non optimal efficacy of therapies available for its treatment. The aim of the present study was to evaluate the efficacy of bromelain, a crude aqueous extract of the stems and immature fruit of pineapple, in the treatment of PLC. MATERIALS AND METHODS: Eight patients (3 males and 5 females) with PLC were enrolled in the study and treated for three months with oral bromelain (40 mg 3 times a day for 1 month, 40 mg twice a day for 1 month and 40 mg/day for 1 month). RESULTS: All patients showed complete clinical recovery after treatment. In 12 months of follow up, two patients experienced relapse 5-6 months after suspension of therapy but responded to another brief cycle of therapy. No side effects were encountered during therapy. CONCLUSIONS: In conclusion bromelain can be considered an effective therapeutic option for PLC; its efficacy could be related to its anti-inflammatory, immunomodulatory and/or anti-viral properties.

See also the NYBC entry:

Bromelain

Digestive/ gastrointestinal support: Vegetarian Enzymes from Douglas Labs; Quiet Digestion from Health Concerns

Here are two approaches for digestive / gastrointestinal support. The first is a combination of digestive enzymes in a vegetarian encapsulation. The second draws on Traditional Chinese Medicine in a formula from Health Concerns.

Vegetarian Enzymes from Douglas Labs, which supplies:

Amylase 4200 D.U. (dextrinizing units)
Protease 12, 500 H.U.T. (hemoglobin units)
Lipase 2400 L.U. (lipase units)
Cellulase 600 C.U.
Suggested dosage: 1-2 tablets three times daily, with meals.

Quiet Digestion (Health Concerns) Each bottle, 90 tablets. Each tablet 750 mg of Poria, Coix, shen chu (a dried mass of wheat flour, fresh aerial parts of Artemisia annua, Xanthium sibiricum, Polygonum hydropiper and water), Magnolia, Angelica, Pueraria, red Atractylodes, Saussurea, Pogostemon, Oryza, Trichosanthes root, Chrysanthemum, halloysite (a mineral product that contains aluminosilicates), citrus, Mentha and malt. Used to reduce gastric distress including pain, cramping, nausea, vomiting, diarrhea, regurgitation, poor appetite; addresses viral or bacterial gastroenteritis as well as motion sickness, hangover and jet lag effects.

Suggested use is 2 tablets taken after meals, 3 times per day; also may be taken between meals or as needed. Chew for best results.