HIV MEDICATIONS-FOOD INTERACTIONS HANDBOOK (And So Much More) 2ND EDITION

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Written by Zaneta M. Pronsky, MS, RD, LDN, FADA Consultant Dietitian, Birchrunville, PA; Former Chief Research Dietitian, Clinical Research Center, Indiana University Medical Center, Indianapolis, In
Sharon Ann Meyer, AA, AS, DTR, President HIV ReSources Inc., Ft. Lauderdale, FL  
Cade Fields-Gardner, MS, RD/LD, Director of Services for the Cutting Edge, Cary, IL

Editors: Sr. Jeanne Patricia Crowe PharmD, RPh, Director of Pharmacy, Camilla Hall Nursing Home; Faculty, Graduate Division, Immaculata College, Immaculata, PA
Veronica S.L. Young PharmD, Asst. Director, Drug Information Service, The University of Texas Health Science Center at San Antonio, San Antonio, TX. Clinical Assistant Professor, University of Texas, College of Pharmacy, Austin, TX
Thomas N. Kakuda PharmD, Associate Clinical Research Scientist, Abbott Laboratories, Clinical Assistant Professor, University of Minnesota, Redwood City, CA
William Roberts MD, PhD, Director Clinical Chemistry, ARUP Laboratories; Assistant Professor of Pathology, University of Utah, Salt Lake City, UT
Advisors: Martin Delaney, Founding Director, Project Inform, San Francisco, CA
Christine Hamilton Smith PhD, RD, Professor, The Marilyn Magaram Center for Food Science, Nutrition & Dietetics, Department of Family Environmental Studies, California State University Northridge, Northridge, CA

The HIV Medications-Food Interactions Handbook is pocket-sized and spiral bound, just like the regular Food Medication Interactions handbook.

 "The HIV Medications & Food Interaction book has been very useful and practical in my practice. It is easy to use, has up to date complete and valuable information dealing with the HIV population.  There is a section on medical nutrition therapy which I particularly like. For those who are assessing body composition, you will find a chart that will be useful to interpret your data. Handy to refer information such as lab evaluations, drug to drug interactions for antiretroviral therapy is included in this book. All health care professionals who deal with the HIV client should have one of these handy pocket books available! " - Vivian Sun, MS, RD, CNSD, The Asst. Director - Food & Nutrition Service, Bellevue Hospital, New York, NY

Note: please read our Disclaimer.

Click here for Sample Page

Table of Contents:

• Guide to the Use of This Book
• Antiretroviral Therapy Guidelines (updated)
• Preface
• Introduction
• Nutrition in HIV Disease (revised & expanded) (see this excerpt)
• Mechanisms of Food Medication Interactions (revised)
• Guidelines for Counseling Medicated Patients (revised)
• Medical Nutrition Therapy For People Living with HIV (revised & expanded)
• FDA Pregnancy Categories
• Food-Medication Interactions (62 new drug listings)
• Antiretroviral Drug-Drug Interactions (revised & expanded, including hydroxyurea) (see this excerpt)
• Tables:
  • Laboratory Values (revised & expanded with additional tests in HIV)
  • Clinical Nutrition Assessment in HIV (ALL NEW SECTION)
  • Segmental Weights for Limbs, Calculation of Ideal Body Weight, BMI
  • CDC Classification of HIV Disease
  • Pressor Agents
  • Potential Interactive Ingredients (revised)
  • Drug-Alcohol (Ethanol) Interactions with HIV Medications (revised)
  • Caffeine Content of Foods and Beverages
  • High Phytate Food Sources
  • Herbal Products: Cautions (revised & expanded)
  • pH and Acid Content of Beverages
  • Magnesium - Significant Dietary Sources (revised)
  • Micronutrient Food Sources (ALL NEW TABLE)
  • Drugs Not Compatible with Tube Feeding
• References (many new references)
• Abbreviations and Symbols (expanded)
• HIV Information Resources (revised, updated, expanded)

Nutrition in HIV Disease
(excerpt from HIV Medication-Food Interactions Handbook)

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The advances of potent life-prolonging medications, used in highly active antiretroviral therapy (HAART), has made HIV a chronic manageable disease with an increased need to focus on nutritional concerns. Because nutritional status impacts the effective management of HIV disease, the importance of optimal nutritional status can not be overstated. Maintenance of appropriate body stores and function becomes a central issue.⁴⁵ Medication side effects increase the need for effective nutritional therapy. Among the current problems seen in long-term management are wasting processes, side-effects and symptoms associated with medication therapies, altered metabolic processes, and changes in physical attributes of the body. To address these problems it will be essential to understand the process of nutritional compromise and its effects on disease management.

Early and successful management of HIV infection will affect the type of nutrition-related problems. One schematic of methods for categorizing and addressing nutrition-related problems is the HIV-specific Medical Nutrition Therapy (MNT) protocols published by the American Dietetic Association.^{94, 95} These protocols along with other strategies for evaluation and management of disease and nutrition-related complication can help to standardize nutritional care. The goals of MNT include strategies to:

• Maximize the effectiveness of medical and pharmacological treatments
• Prevent the development of specific nutrient deficiencies
• Optimize nutrition status, immunity and overall well being
• Prevent and manage medication side effects
• Prevent loss of body weight, lean body mass and other facets of malnutrition
• Minimize health care costs

Baseline evaluation and care includes a nutrition risk assessment and nutrition education. Nutrition education should include basic food principles, food safety issues, strategies for prevention and reversal of weight and muscle tissue loss and potential food medication interactions. Nutrition risk screening includes a review of the risk factors and indicators of nutritional compromise. Criteria generally include food-related habits and access to food, weight and body composition changes, medical profile (infections, injuries, medications), use of complementary therapies and "recreational" drugs. Assessment parameters are discussed in the assessment section on page 195.

Multiple medication regimens may have effects such as GI upset, diarrhea, nausea, vomiting, malabsorption and/or anorexia, that negatively affect the patient's ability to eat an adequate diet. These effects, combined with depression, apathy, fatigue and/or financial restrictions, often lead to a specific form of malnutrition called HIV or AIDS related wasting syndrome. Because of the important role played by lean tissues to support life processes, medication and other therapies, the loss of lean tissues is a major concern. Even asymptomatic patients may experience muscle wasting and significant clinical problems due to disease processes, symptoms, and malabsorption of nutrients³¹, despite decreased viral load and improved immune function as a result of HAART.⁷⁵

Some data suggest that as little as 3% to 5% loss of weight from baseline over a 4 month period increases the risk of opportunistic complications and death.⁹⁰ Involuntary weight loss of more than 5% within 6 months or 10% within 12 months is increasingly regarded as an acceptable criterion for wasting. If one can anticipate the potential for weight loss and wasting, prevention and effective treatment of nutrition-related problems may be accomplished.

HIV disease and its complications deplete nutritional stores as a result of the body's normal response to infection, therefore causing nutrition related problems. When weight alone is used as the only criteria for the wasting process, this may underestimate the degree of tissue and functional losses. Metabolic stress responses cause catabolism of protein stores to provide energy and enhance the amino acid pool. Fluid shifts also occur, increasing fluids outside of cells while intracellular fluid associated with protein stores is depleted. HIV does not appear to become dormant and provides a continuous message to the body to respond. Even with medication, the virus may establish a "set-point" and reproduce as much as necessary to maintain that level of viral load. This continuous assault may require adaptation by the body to tolerate and survive the effects of the virus. For instance, if muscle stores are compromised, the body may adapt by lowering energy levels thus causing chronic fatigue.

Bioelectrical impedance analysis (BIA) is used to evaluate body composition. BIA measures the body's electrical properties. Using these measurements, we can estimate muscle and other lean tissue, fat and water. BCM (body cell mass), ECT (extracellular tissue), FFM (fat free mass), TBW (total body water), extracellular and intracellular water and fat compartments. The FFM compartment can be broken down to BCM and ECT. BCM is most associated with survival and is primarily made up of muscles and organs, which process nutrients and medications. The ECT compartment is comprised of structure and transport tissues (such as bone, collagen and fluids outside of BCM). Phase angle is calculated and appears to reflect the ratio of body compartments.

 Body composition evaluation through anthropometry and BIA is further discussed in the assessment section on page 195. Periodic BIA has been used to evaluate the efficacy of medical, nutritional and other therapies, such as appetite stimulant(s), anabolic medications and fitness programs. BIA can help to determine the need for additional evaluation such as hormonal levels and anticipates compromises in body functions. Unfortunately, weight loss in HIV is often protein loss, while gain may be largely fat, but little muscle restoration. BIA can help to determine these body changes and help medical professionals redesign various aspects of the health care plan including diet, fitness programs, medication or additional laboratory testing such as testosterone levels.

Continuous assault of HIV viral load and disease complications may deplete the body of nutrients and deficiency syndromes may develop. Hypermetabolism and metabolic dysfunction occur causing inefficient nutrient metabolism. Studies have demonstrated that HIV infection increases the risk of developing deficient serum levels of beta carotene, and the vitamins riboflavin (Vit B₂), folic acid, retinol (Vit A), pyridoxine (Vit B₆), cobalamin (Vit B₁₂), ascorbic acid (Vit C) and tocopherol (Vit E). Deficient serum levels of the minerals iron, magnesium, selenium, copper and zinc are also common in HIV-positive patients. Micronutrient deficiencies are sometimes evident even in the early stages of HIV infection and may contribute to disease progression.⁹⁹ Rather than individual nutrient supplements, a complete multivitamin-mineral supplement that provides 100% to 200% of the RDAs is suggested. Some clinicians routinely suggest a vitamin B complex and antioxidant formula as well.⁹⁹

Abnormal body shape and body fat distribution, low serum testosterone concentration, high serum cholesterol and triglycerides, insulin and other hormonal resistance, (often referred to as lipodystrophy syndrome) is a newly recognized complication in long-term survivors of HIV disease. These metabolic abnormalities add to the difficulty of managing HIV infection ^{110 , 111} see p 22. Changes in body dimensions include both the loss of subcutaneous fat stores in peripheral limbs, face, buttocks, and elsewhere and the deposition of fat in the body trunk areas including the visceral region of the abdomen, back, neck, and flanks. Preliminary studies showed that patients with buffalo humps may have lower HDL concentrations than those without humps.¹¹⁵ This needs further evaluation, however, because HIV infection itself leads to decreased HDL concentrations.

Resistance training along with aerobic exercise may help to reduce total body fat and trunk fat.¹¹⁶

If possible, HIV-positive people should enlist the help of a fitness trainer who is knowledgeable about HIV/AIDS to design an exercise program that matches their fitness level and medical status. Additional medications, such as sex hormones, growth hormone, antidiabetic and antihyperlipidemic drugs have been empirically used in an effort to reduce the effects of altered fat deposition.¹¹⁰

Heart disease and diabetes that can occur with the use of HAART must be addressed with effective nutrition and medication therapy. ^{105, 111} Dietary modification may be most helpful to treat very high triglyceride levels, since extreme elevations are related to circulating chylomicrons whose fat is of dietary origin.¹¹⁰ If medication is also necessary to control lipid and/or glucose levels, the clinician should monitor for drug interactions and additional potential for the compromise of nutrition status.

Some HIV-positive people may follow harmful fad diets with the hope of improving nutrition status. Diets such as the popular high protein regimen are not recommended without close dietitian supervision because they usually increase saturated fat intake, cause excessive work for the kidney and liver, and may lead to heart disease, kidney stones, and an increased risk for osteoporosis.¹¹⁴ Since stored carbohydrate contains large amounts of water, which is eliminated when dieters switch to a low carbohydrate diet, these regimens can also result in the loss of both water and the weight associated with it.

Recent focus on drug-drug interactions, drug interactions with food, food components or dietary supplements and the effects of phytochemicals on P450 enzyme activity has caused both clinicians and HIV-positive people to restructure medication scheduling strategies. In addition to medications to combat and manage HIV infection, many patients also take medications for symptom management or nutritional rehabilitation. Symptom management strategies (see also MNT section p 22) are typically aimed at supporting tolerance and effectiveness of drug therapies as well as quality of life. Nutrition rehabilitation includes nutrient support, exercise, antiretroviral therapy (which requires strict adherence to drug regimens¹¹²), prevention and treatment of other infection and/or neoplasm, and immune function restoration.

The effectiveness and tolerability of some drugs can be affected by the body's nutritional stores. The overall bioavailability and efficacy of a drug can be influenced by an individual's plasma protein concentration (as in the case of a highly protein-bound medication) and by the drug's volume of distribution. Both factors are affected by nutritional status. Information about the actual incidence and severity of food medication interactions is incomplete at this time, especially with many of the newly approved drugs. Consideration of these interactions, as well as drug-drug (see p139) and drug-herbal (see p 220) interactions, is an important part of a multi-faceted health care plan.

Medications used to try to restore positive nutritional status include vitamins, minerals, appetite stimulants such as megestrol acetate (Megace) or dronabinol (Marinol), anticytokine therapies such as thalidomide (Thalomid) and anabolic therapies (such as growth hormone or anabolic steroids). Choosing to prescribe, recommend or use these drugs should be part of a care plan for prevention and treatment of nutritional compromise. Combinations of therapies are likely to be more effective in some cases, such as the use of megestrol acetate with anabolic agents and resistance exercise.¹¹³

Value of MNT (Medical Nutrition Therapy)

MNT to maintain or improve nutritional status is a necessary part of the management of HIV disease. Individualization of fluid, calorie, protein and other nutrient needs with respect to and consideration of cultural aspects, current food habits, nutrition-related beliefs and medical status may determine the patient's ability to manage his/her disease. Successful treatment of wasting syndrome, altered fat distribution and metabolic abnormalities improves not only the patient's medical status, but also self esteem and willingness to continue to fight the effects of HIV.

In the MNT section, (p 22) we present MNT to alleviate adverse nutrition-related effects of HIV. These suggestions may not work for all patients. The suggestions may work for particular patients for a while and then fail. New therapies may be tried with short-term success. It can be very frustrating and tedious for both the patient and the health care provider to continually adjust strategies.

Ultimately, the goal is to provide HIV-positive people with the best options for disease management to improve the length, quality, and productivity of their lives.

HIV Drug-Drug Interactions: Introduction
(excerpt from HIV Medication-Food Interactions Handbook)

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SELECTED ANTIRETROVIRAL DRUG-DRUG INTERACTIONS

    Drug-drug interactions cause problems that range from low-grade symptoms to life-threatening events. For instance, an interaction between amphetamines and protease inhibitors increases amphetamine levels and may result in a fatal overdose. Some drug-drug interactions may have desirable consequences such as increasing serum level of one or both drugs, allowing lower dose(s).  An example is the interaction between saquinavir and ritonavir which increases the AUC of saquinavir and allows for a lower dose of saquinavir while maintaining effectiveness. 
     In the “Mechanisms of Interactions” section p 14-19 causes of interactions between food and medication are reviewed.  The same types of interactions occur between drugs. Pharmacokinetic interactions affect absorption, distribution, metabolism or excretion of drug(s).  Pharmacokinetic interactions result in changes in bioavailability and/or concentration of medication. The effectiveness and safety of drugs with a narrow therapeutic index are more likely to be affected by drug interactions.
     Pharmacokinetic interactions most commonly involve changes in metabolism as a result of inhibition of metabolism or induction of metabolism. Drugs most likely to interact are those metabolized by the cytochrome P450 enzyme system (CYP). Some drugs are CYP inhibitors, resulting in slower metabolism and higher drug serum level. Other drugs induce (accelerate) the CYP system, causing the drug to pass through the body faster and achieve lower drug serum level. CYP isoenzymes commonly affected are CYP3A4, CYP3A, CYP2D6, CYP2C9, CYP2C19. Ritonavir is a very potent inhibitor of multiple CYP enzymes, while nevirapine induces CYP3A4 enzymes.
     Pharmacodynamic interactions result in antagonism of drug action or additive or synergistic action, without changing drug concentration. Pharmacodynamic interactions alter drug(s) action or result in toxicity.
     Some interactions are of such magnitude as to endanger the patient, thus requiring avoidance of the combination of drugs.
     Dosage adjustment(s) may be necessary.  If a drug’s metabolism is inhibited by an interaction, the drug level will rise and a lower dose may be necessary to prevent toxicity.  Individuals must be monitored for signs and symptoms of toxicity if the interaction potentially increases drug blood level.
     It also may be possible to use such an interaction in a positive manner to lower the dose as mentioned above for saquinavir and ritonavir. Other dual protease inhibitor combinations in which interactions are used in a positive manner are ritonavir/indinavir, nelfinavir/saquinavir, delavirdine/saquinavir and ritonavir/lopinavir (Kaletra).
     If a drug’s metabolism is induced (accelerated), the drug’s level will fall and a higher dose of the drug may be necessary to maintain effective drug levels. If the interaction potentially decreases levels of an antiretroviral, it may be appropriate to more closely monitor for antiretroviral efficacy (CD4, viral load, clinical status).
     Selected published drug-drug interactions, but not every possible interaction, are presented in this table.  This table is intended only to alert the reader to some possible interactions.   It is not intended to replace the advice of health care professionals.  Many factors affect the likelihood of interactions, including nutritional status, clinical category of HIV disease, age of the patient, gender, genetic predisposition, which affects the rate of drug metabolism; hepatic, renal or cardiac impairment; smoking, “recreational” drug or alcohol use.

Antiretroviral drugs are classified as follows (* = investigational drug):

 nucleoside/nucleotide reverse transcriptase inhibitors (NRTI):

abacavir (ABV) Ziagen	emtricitabine (FTC) Coviracil*
didanosine (ddI) Videx	lamivudine (3TC) Epivir
stavudine (d4T) Zerit	zalcitabine (ddC) Hivid
zidovudine (ZDV or AZT) Retrovir	tenofovir (GS1278) PMPA* (NtRTI-nucleotide analog)

non-nucleoside reverse transcriptase inhibitors (NNRTI):

delavirdine (DLV) Rescriptor	efavirenz (DMP-266) Sustiva
nevirapine (NVP) Viramune	capravirine*

protease inhibitors (PI):

amprenavir (APV) Agenerase	indinavir (IDV) Crixivan
lopinavir (ABT-378) Kaletra (lopinavir/ritonavir)	nelfinavir (NFV) Viracept
ritonavir (RTV) Norvir	saquinavir (SQV) Invirase  (HGC)
tipranavir (TPV)*	or Fortovase (soft gel capsule or SGC)

fusion inhibitor:

pentafuside (T-20)*

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HIV Drug-Drug Interactions: Sample Page
(excerpt from HIV Medication-Food Interactions Handbook)

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