Nausea, Vomiting and Diarrhea

When it comes to side effects of HIV medications, the gastrointestinal tract—the gut—is one of the most commonly affected organ systems in the body. Nausea, vomiting, and diarrhea are three ways in which the gut deals with toxins. These are important defense mechanisms, as they help keep dangerous germs—such as bacteria, viruses, and other bugs—as well as truly harmful chemicals out of the body. Although antiretrovirals (ARVs) are designed to fight HIV, the gut often considers these HIV meds to be harmful and may turn on its defense mechanisms to clear them from the body.

These side effects don't occur in everyone, and fortunately when they occur as side effects of HIV treatment, they are usually mild and tend to diminish after the first few days or weeks of treatment. Even so, they can have a serious impact on your quality of life and need to be addressed as a part of your overall health so you can get the most out of your treatment.

If nausea, diarrhea, and vomiting are severe or prolonged, they can lead to serious health problems and can prevent HIV meds from entering the bloodstream and from doing what they need to do. You should report these symptoms to your doctor, to determine if they are a side effect of treatment or a symptom of something more serious.

Nausea and Vomiting
Two of the most common gut-related side effects of HIV treatment are nausea and vomiting. Most HIV-positive people who experience nausea or vomiting usually do so after starting a new HIV drug regimen. In most cases, these side effects eventually lessen or go away completely after the first few days or weeks of treatment.

If nausea is seriously affecting your quality of life, including your ability to eat, or if your vomiting continues for more than just a few days, you should contact your doctor. Even though nausea and vomiting are common side effects, they should not be considered a normal part of living with HIV. Here are a few ways to manage these side effects:

• Switch treatments. One option may be to replace the offending drug with a similar drug that may not cause nausea or vomiting. Unfortunately, when taking a drug combo, it is often difficult to determine which one is the culprit. It can also be difficult to predict whether nausea or vomiting will improve (or get worse) upon switching to another drug. What's more, switching to another drug might not be possible for patients who have a limited number of drugs to choose from (i.e. they may be resistant to other drugs). As a result, switching treatments is often reserved for people who experience profound nausea or vomiting.

• Prescription treatments. A class of drugs called antiemetics—medicines that prevent or control nausea and vomiting—is available by prescription. These drugs work by blocking receptors in the brain's vomiting center. Unfortunately, antiemetics are not without side effects of their own: They have a tendency to make people feel drowsy or feel mildly sedated.
  
  Some of the most commonly prescribed antiemetics include Zofran (ondansetron), Kytril (granisetron), Anzemet (dolasetron) and Decadron (dexamethasone). Another option is Marinol (dronabinol), a drug that contains a synthetic version of THC, the active ingredient in marijuana. Not all drugs are equally effective for all patients, and antiemetics sometimes work best when given in various combinations. These drugs work best if they are taken 30 to 45 minutes before taking any ARVs. It's also important to note that some of the antiemetics, particularly Reglan (metoclopramide), can be dangerous if taken at the same time as some of the protease inhibitors, including Norvir (ritonavir) and Kaletra (lopinavir/ritonavir).

• Marijuana has been reported to be effective for nausea and appetite loss. It is important to note that smoking any substance is dangerous to the lungs and may aggravate existing lung problems, particularly asthma or bronchitis. Eating marijuana—by cooking with it (pot brownies, etc.)—is considered by some to be a safer way to experience the medicinal effects of this drug. Though the federal government still considers marijuana an illegal substance, several states have legalized it for medicinal and recreational use.

Other tips

• Eat small meals frequently instead of two or three large ones.
• Cut a lemon and smell the slices to lessen nausea.
• Ginger has long been used to help nausea. Drinking ginger ale or ginger tea may be helpful.
• Bland foods are easier to digest. Stick to foods low in fat but high in starches and carbohydrates.
• Relax before meals and chew slowly.
• Breathe deeply and slowly when you first feel nauseated.
• Acupressure bands (known as Sea-Bands) placed on the forearm about two inches up from the wrist may help alleviate nausea.

Diarrhea
Diarrhea-loose, watery stools—is often a short—term side effect of HIV meds and usually improves after a few days or weeks of treatment, unless there is an infection-related cause. Diarrhea is a symptom of many diseases and complications that can occur in HIV-positive people, so it is important that you report it to your doctor.

Generally speaking, diarrhea that occurs five times or more a day, for five or more consecutive days, and results in five pounds or more of weight loss, should always be reported and managed to prevent dehydration.

Diarrhea can also be a long-term problem for people taking certain ARV drugs, including Viracept (nelfinavir). While the diarrhea associated with nelfinavir doesn't usually lead to dehydration or other life-threatening problems, it can be a nuisance and may have a profound affect on a person's quality of life.

Here are a few tips for managing diarrhea:
Make dietary adjustments. Some foods can cause or worsen diarrhea, while others can help to relieve it.

• The BRATT diet – consisting of Bananas, Rice (white), Apple juice or sauce, Toast and Tea (herbal) – may help control diarrhea.
• Foods high in fiber are high in starch are recommended.
• Clear juices (apple, peach or pear) are less harsh than those high in acid (orange or grapefruit).
• Eat small amounts of food throughout the day, instead of three large meals.
• Add nutmeg to foods to slow down the movement of material through the intestines.
• Avoid foods that can make diarrhea worse, such as coffee or other caffeinated beverages, alcohol, chocolate, fried and fatty foods, spicy foods, fat substitutes, dairy products, highly processed foods and foods high in soluble fiber, such as raw vegetables, potato peels, beans and brown rice.

Increase your fluids. Try to drink at least three quarts of fluid per day, unless your doctor tells you not to do so. This will help to prevent dehydration and malnutrition, which may result from diarrhea. Drinking clear juices and sports drinks at room temperature is recommended.
Over-the-counter and prescription drugs. There are several over-the-counter (OTC) drugs available, including Imodium AD, Kaopectate and Metamucil. Metamucil is commonly used as a laxative, but its fiber contents can also absorb water in the colon and help control diarrhea. Some of the anti-diarrheal drugs available by prescription include Fulyzaq (crofelemer), Lomotil (diphenoxylate), pancrelipase (a pancreatic enzyme sold under many brand names), and tincture of opium. As with drugs used to control nausea and vomiting, anti-diarrhea drugs work best if taken 30 to 45 minutes before taking the medication causing the diarrhea.
Complementary therapies. Peppermint and ginger may calm the gut and are often used to control diarrhea. Other complementary therapies include the probiotic Lactobacillus acidophilus (available in capsules and yogurt), glutamine and the Chinese herbal blend Quiet Digestion.

Last Revised: February 14, 2016

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