HIV MEDICATIONS-FOOD INTERACTIONS HANDBOOK

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by Zaneta M. Pronsky, MS, RD, FADA
and Cade Fields-Gardner, MS, RD/LD

Note: please read our Disclaimer.

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

Click here for Sample Page

Table of Contents:

• Guide to the Use of This Book
• HIV Information Resources
• Preface
• Introduction
• Nutrition and HIV (see this excerpt)
• Mechanisms of Interactions
• Guidelines for Counseling Medicated Patients
• Medical Nutrition Therapy to Assist in Relief of Medication Side Effects
• Abbreviations and Symbols
• Antiretroviral Therapy Guidelines
• FDA Pregnancy Categories
• Food-Medication Interactions
• HIV Drug-Drug Interactions(see this excerpt)
• Tables:
  • Laboratory Values
  • Comparison of Height-Weight Tables
  • Segmental Weights for Limbs, Calculation of Ideal Body Weight
  • CDC Classification of HIV Disease
  • Potential Interactive Ingredients
  • Drug-Alcohol (Ethanol) Interactions
  • Caffeine Content of Foods and Beverages
  • High Phytate Food Sources
  • Pressor Agents
  • Herbal Teas & Remedies: Cautions
  • pH and Acid Content of Beverages
  • Drugs Not Compatible with Tube Feeding
• References

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

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Early and successful management of HIV infection will reduce nutrition related problems. Although it makes sense that lowering viral load would reverse nutrition problems, asymptomatic patients may experience muscle wasting and malabsorption. For patients who experience chronic nutritional compromise, restoration must include more than treatment of HIV infection.

HIV disease and its complications deplete nutritional stores as a result of normal response to infection. Responses to infection include a metabolic stress response that causes catabolism of protein stores to provide energy and enhance the amino acid pool. Nutrition related problems may occur because of the long term stress response in HIV infection. HIV does not appear to become dormant at any point and provides a continuous message to the body to respond. 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 which causes chronic fatigue.

Continuous assault 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 deficient serum levels of Vitamins A, B6, B12, C, E and folic acid. Deficient serum levels of the minerals iron, magnesium, selenium, copper and zinc are also common in HIV infected patients. Rather than individual nutrient supplements, a complete multivitamin-mineral supplement which provides 100 to 200% of the RDAs is suggested.

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 and by the drug's volume of distribution. Both factors are affected by nutritional status.

Multiple medication regimens may have effects such as GI upset, diarrhea, nausea, vomiting, malabsorption and/or anorexia which 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. The CDC defines wasting syndrome as unintentional weight loss of 10% or more, with weakness and fever or diarrhea for more than 30 days.

Stronger and more current data suggest that as little as 5% loss of weight from baseline over a 4 month period increases the risk of mortality. If one can anticipate the potential for such effects, prevention and effective treatment of nutrition-related problems may be accomplished.

In addition to medications to combat and manage HIV infection, many patients also take medications for symptom management or nutritional rehabilitation. Symptom management strategies 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, prevention and treatment of other infection and/or neoplasm, and immune function restoration.

Medications used to try to restore positive nutritional status may include vitamins, minerals, appetite stimulants such as megestrol acetate (Megace) or dronabinol (Marinol), anticytokine therapies such as thalidomide (Thalidomid) 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. We do not yet have complete information about the actual incidence and severity of food medication interactions, especially with approval of many new drugs. Consideration of these interactions, as well as drug-drug interactions, is an important part of a multi-faceted health care plan.

Medical nutrition therapy to maintain or improve nutritional status is a necessary part of 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 improves not only the patient's medical status, but also self esteem and willingness to continue to fight HIV effects.

In the Nutritional Intervention section, we present medical nutrition therapy to alleviate nutrition related side effects. These suggestions do 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 care provider to continually adjust strategies.

Ultimately, the goal is to provide HIV patients 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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Drug-drug interactions cause problems that range from low-grade symptoms to life-threatening events. For instance, an interaction between indinavir and astemizole may cause cardiotoxicity and death. Some drug-drug interactions may have desirable consequences such as increasing serum levels 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 10 - 15 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.

Pharmacodynamic interactions are those which result in antagonism of drug action or additive or synergistic action, without changing drug concentration. Pharmacodynamic interactions can alter drug(s) action or result in toxicity.

Pharmacokinetic interactions most commonly involve changes in metabolism as a result of inhibition of metabolism or induction of metabolism. Drugs that are 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 levels. Other drugs induce (accelerate) the CYP system, causing the drug to pass through the body faster and achieve lower drug serum levels. Ritonavir is a very potent CYP inhibitor, while nevirapine induces a P450 enzyme.

Selected published drug-drug interactions are presented in this table. Many factors can affect the likelihood of interactions, including clinical status of the patient, age of the patient, genetic predisposition which causes poor metabolism; hepatic, renal or cardiac impairment; smoking or alcohol intake.

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

• nucleoside reverse transcriptase inhibitors (NRTI):

  abacavir (1592-U89) Ziagen*	adefovir (GS 840) Preveon*
  didanosine (ddI) Videx	lamivudine (3TC) Epivir
  stavudine (d4T) Zerit	zalcitabine (ddC) Hivid
  zidovudine (ZDV or AZT) Retrovir

• non-nucleoside reverse transcriptase inhibitors (NNRTI):

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

• protease inhibitors (PI):

  amprenavir (APV) Agenerase*	indinavir (IDV) Crixivan
  nelfinavir (NFV) Viracept	ritonavir (RTV) Norvir
  saquinavir (SQV) Invirase or Fortovase (soft gel capsule or SGC)

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

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