September #63 : Pills! Chills! Thrills! Spills! - by Lark Lands, PhD

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Table of Contents

POZ Side FX

Long Live The Queens

How To Vote

Pills! Chills! Thrills! Spills!

Keeping Up With The Jones

Alabama Bound

Green Alert!

Publisher’s Letter

Mailbox

Double Identity

Say What?

Thespian Avengers

Catching Up With...

Off-Line Service

Data Drill

Hair Comes The Condoms

There’s No Place Like Om

Straight To The Heart

Milestones

Second Sex First

Dis-Advantage-S

He’s All That

Recovery Lite

Road Trippin'

Beyond The Valley Of The Dolls

Change of Heart

Crossing the Liver

Warning: Natural Selection

Dandelion Whine

Teen Talk

Skin Deep

Resistance Assistance

Dishes On The Side

Kentucky Woman

Comfort Zone

The Funky Fungus Among Us



Most Popular Lessons

The HIV Life Cycle

Shingles

Herpes Simplex Virus

Syphilis & Neurosyphilis

Treatments for Opportunistic Infections (OIs)

What is AIDS & HIV?

Hepatitis & HIV


email print

September 2000

Pills! Chills! Thrills! Spills!

by Lark Lands, PhD

Drugs that fight HIV and opportunistic infections are lengthening life spans, but the list of troubling side effects is also growing. Lark Lands tells you everything you wanted to know about med-related nasties but were afraid to ask.

AIDS drugs—like most others—have the potential to produce not only great benefits but also discomfort in the form of troubling side effects. These conditions can be acute or slow-building, dangerous or merely bothersome, but regardless, it’s important to prepare yourself to respond. First and foremost, you must be in touch with your body so you can tell if something’s amiss and be able to clearly describe your symptoms. And you must be in touch with your doctor, so a medical judgment can be made. Which leads to two critical rules: No. 1: Tell your doc everything, from beginning to end—if a symptom appears, changes, disappears or reappears. No. 2: Always follow Rule No. 1.

If you’ve talked to doc about possible side effects before starting therapy, you’ll be better prepared. If there’s one that might be life-threatening, you'll know what to watch for. If it’s likely that this, that or the other will improve over time, it might be easier to convince yourself to stick with the drug. (You'll want to check out “Dish on the Side,” a range of community information resources,.)

Know that as the body adjusts to a new med, you may experience headaches, nausea, muscle pain or dizziness, all of which may disappear within two to six weeks. Other drug-specific symptoms may diminish or become more manageable over time. And know also that you’re not alone: Countless HIVers are feeling the same things you are—and misery loves company. So even if the symptom seems too awful to handle long term, talk to your co-sufferers, soak a few shoulders if you must and hang in there for at least six to eight weeks after starting the offending med, if possible. And never say to yourself that you’ve been on this combo for three years now, so that weird sensation you’ve started feeling couldn’t possibly be tied to the meds. It could. New side effects can appear at any time. Apply rules No. 1 and 2.

Regardless of the specific symptom, always seek a full diagnosis of all possible contributing causes. What you’re feeling may be the med—or it could be a hormone problem, a nutrient deficiency, an infection, depression, HIV itself or countless other factors. By examining all the possibilities, you’ll maximize your chances of eliminating the symptom and maybe avoid switching meds unnecessarily. 

The list of side effects that follows includes a wide range of strategies that may allow you to have your cake and eat it too—to experience the anti-HIV benefits of the meds but minimize their downsides by using other drugs, herbs, nutrients and self-care measures.

Changing drugs can be your last-ditch option. The possibilities will, of course, depend on your treatment history and current needs. But (Rule No. 1) always ask doc.

Appetite Loss
“No thanks, I couldn’t possibly”


Many different medications can cause a lack of interest in eating by either directly suppressing the appetite or by unpleasantly altering the sense of smell or taste (“taste perversion”). Or drug-induced nausea can make the very thought of face-stuffing repulsive (see Nausea). Although discontinuing the offending drug will usually bring quick relief, this is often not the best option, so consider some other approaches. First, there may be other causes: infections and fever (treat ’em); abnormal levels of hormones (especially low testosterone—replace ’em) or of cytokines (especially tumor necrosis factor—block it either with  drugs or the nutrients N-acetyl-cysteine, 500 mg, three times daily, and L-carnitine, 1,000 mg, three times daily); depression (shrink it); and nutrient deficiencies (particularly of zinc, try 75 mg daily). The latter is one of those vicious circles: The appetite loss has caused inadequate nutrient intake, which in turn triggers appetite loss. The solution is usually a combination of appetite boosters, high-nutrition eating and supplements.

Marijuana and its synthetic cousin, Marinol (dronabinol), are both powerful appetite stimulants. Some people object to the mental effects, but at least with Marinol the head trips can be lessened by taking the drug before bedtime because the appetite stimulation often carries over into the next day. Megace (megestrol) is another option, but it can suppress testosterone production, an unwanted side effect. The antihistamine cyproheptadine (Periactin), usually prescribed for allergies, can be an effective appetite booster.

If all else fails, you may have to force yourself to eat on a schedule, substituting multiple smaller snacks for three big meals. Try anything that helps spark your interest in food—new seasonings or substitutes for odd-tasting foods, sauces to cover metallic-tasting protein foods, cooled foods to lessen objectionable smells, and tasty snacks squirreled away for moments of rekindled appetite. When consuming a whole meal seems impossible, try a high-calorie shake or blended soup—drinking a meal may be easier than eating one. A potent multivitamin/
mineral can help make up for inadequate intake of particular nutrients (a good idea anyway, as most HIVers are deficient).

Body Distortions
Humps and bumps and lumps…oh my!


Lipodystrophy-associated body changes—loss of fat in the face, arms, buttocks and legs; enlarged breasts and bellies; buffalo humps between the shoulders; and lipomas (fatty tumors) anywhere—are at the top of most HIVers’ “Please, God, no!” lists. The cause is not understood, but many researchers think that it’s probably a combination of med effects and the HIV infection itself (including the immune system’s response to it). Unfortunately, discontinuing meds does not always reverse the problems, though there have been reports    of gradual improvements over time. Although too many doctors still think of this as a “cosmetic” issue, it’s more than skin deep when the buffalo hump creates difficulty sleeping, headaches, neck pain and obstructed side vision; the abdominal fat causes difficulty breathing, digestive problems and back pain; and the facial fat loss and overall body distortion can cause profound emotional distress.

Therapies differ depending on the affected area and whether the problem is fat excess or loss. For big bellies and buffalo humps, human growth hormone (Serostim) has been shown by several studies and numerous anecdotal reports to work well, although it may take several months to see the full results. The standard approach is subcutaneous (under the skin) injections given in doses of 6 mg daily, but treatment activists have found that every-other-day dosing, sometimes using below normal amounts (only 2 to 3 mg), may work just as well and has the advantage of reducing or preventing potential side effects—swollen joints and carpal tunnel syndrome—at higher doses. Although under study for lipo treatment, Serostim is only approved for standard wasting, making coverage of this expensive drug dependent on the HIVer and doctor reporting a 10 percent weight loss—the basis of a wasting diagnosis.

Plastic surgery approaches include fat removal via liposuction or other surgical techniques (effective for buffalo humps, breast enlargement and lipomas but too risky for abdominal fat) and facial restoration via injections of fat taken from other parts of the body, collagen or related substances (see “The New AIDS Look,” POZ, June 2000).

Suggestions on preventing undesirable body changes in the first place depend on which causative theory you believe. There is some support for the possibility that dysfunctional mitochondria (your cells’ energy factories), caused by nucleoside analogues (“nukes,” drugs in the AZT class), may contribute to these problems. The chief proponent of this theory, Kees Brinkman, MD, of the Netherlands, believes that impaired mitochondria may underlie not only some lipo-related problems but also neuropathy, myopathy (muscle pain and weakness) and lactic acidosis (a potentially fatal condition in which rising lactic acid levels can cause kidney and liver failure). Brinkman has suggested that using the nutrients coenzyme Q-10 (an antioxidant), riboflavin (a B vitamin) and L-carnitine (an amino acid), with a steady supply of all the antioxidants (vitamins E and C, alpha-lipoic acid, selenium and so on), might be protective. Early research showing reversal of AZT-induced myopathy with carnitine (prescribed as Carnitor, given in doses of 1,000 mg, three times per day) lends support to his theory. Other researchers are looking at the possible link between the fat abnormalities and insulin resistance caused by protease inhibitors (see Insulin Resistance and Diabetes).

Bone Death
Holey hips, Batman!
The thigh bone’s no longer connected to the hip bone. That could be your problem if you develop the tongue-trippingly named avascular necrosis of the femoral head—a bone disease in which there is tissue death in the thigh bone’s top end, a section that is part of your hip. Studies from both Georgetown University and the University of California at San Francisco have indicated that protease inhibitors can cause this hip-nipping nasty. Corticosteroid drugs and alcohol abuse can also contribute to it. If detected early on, small holes can be drilled in the bone to increase blood flow and prevent worsening. If it progresses too far, however, the only thing that works is hip replacement. Ouch.

Diarrhea
The runs for your money

Diarrhea—an increase in the frequency and decrease in the consistency of stools—can be caused by many antiretrovirals. The two most widely reported culprits are nelfinavir (Viracept) and ritonavir (Norvir). And other types of antivirals, such as the antiherpes drug acyclovir (Zovirax), as well as many antibiotics, can also have this effect. In some cases, the diarrhea may diminish after a period of time on the drug, but too often it will become your constant companion.
If the onset or sudden worsening of diarrhea occurs shortly after beginning a med, it’s a likely suspect. In this case, the best solution, if possible, may be drug substitution, which will usually result in a quick disappearance of the problem. But there’s often more than one cause, so treatment requires aggressive diagnosis to pin down all possible factors. In addition to meds, other causes can include infections and parasites (treat ’em); fat intolerance and malabsorption (cut back on dietary fat and take lipase, the fat-digesting enzyme, with meals); lactose intolerance (eliminate or decrease dairy products and take lactase enzyme when those products are consumed); excessive sugar or caffeine (cut back); and stress (chill).

When causes can’t be eliminated, it may be time for standard antidiarrheal agents (Kaopectate or Pepto-Bismol), antimotility agents (Imodium, Lomotil, tincture of opium, paregoric or opiates) or luminal-acting (stool-bulking) agents (cholestyramine, pectin, Kaolin or fiber supplements) to relieve symptoms. Also, many PWAs have reported great benefits from SB (Shaman Botanicals) Normal Stool Formula—a newly marketed, over-the-counter rain-forest tree-sap extract—for med-induced runs. For diarrhea caused by nelfinavir, calcium taken in doses of 500 mg, twice per day, has been shown to work well in a small study. The amino acid L-glutamine, taken in doses of 5 to 30 grams daily (powder is best, mixed in water or juice), can both help to heal diarrhea-damaged intestines and reduce the runs by enhancing water and sodium absorption across the wall of the small intestine.

Increasing your intake of soluble-fiber foods (as opposed to the insoluble type found in wheat bran or popcorn) can also help since they absorb water and expand, binding together the intestinal contents. This bulks up the stool and slows the passage of food. Included are peeled apples or applesauce made from them, oatmeal, oat bran, white rice, barley, apricots, peaches, pears, plums, grapes, berries, melons, nectarines, prunes, raisins and bananas, as well as soluble-fiber supplements like psyllium (Metamucil) and citrus peel (Citrucel). Fiber intake should be slowly increased to help limit the possible increase in intestinal gas (see Gas and Bloating). For as long as diarrhea continues, it’s crucial to consume calories (make every bite count toward high-quality nutrition) and healthful liquids (water, juices, herb teas, broth and fruit-juice smoothies) to replace what’s bound for the bowl.

Fatigue
Sick and tired of being sick and tired?

Fatigue—crawling out of bed feeling like you’ve been hit by a truck and going downhill from there—can be caused by HAART combos. Just taking all those drugs can sap some people’s strength. But the meds that can cause bone marrow suppression and anemia are the worst offenders, among them AZT (Retrovir), d4T (Zerit), abacavir (Ziagen), ganciclovir, sulfa antibiotics, alpha interferon, hydroxyurea, pyrimethamine, pentamidine and various cancer chemotherapies. Because many factors can contribute to energy loss, it’s important to consider that you may also have infections (treat ’em); inadequate nutrition (eat well and often); many nutrient deficiencies, especially B-12 (supplement with nasal gel, one to three times per week); hormonal deficiencies (replace ’em); depression (get therapy or meds); and inadequate rest (take naps and address insomnia).

The energy loss caused by meds will sometimes disappear after a period of time on those drugs (so you may want to consider waiting to see if the fatigue passes), and will often disappear fairly quickly if they’re stopped. Because it seems to be an individual response—some meds may cause fatigue in you but not in your friends—drug switching may help.

Whether you swap or not, anyone with fatigue should check blood counts immediately. Anemia—a red-blood-cell malfunction indicated by decreased hemoglobin and hematocrit levels—is experienced by more than three-fourths of those with AIDS, and by about one-fourth or more of those with less advanced disease (see “Breathless,” POZ, March 1999). Unfortunately, anemia too often goes untreated. The result is needless fatigue and weakness, along with shortness of breath, heart palpitations, increased susceptibility to infections, and lowered quality—and length—of life. In fact, a 3,200-person study found that, regardless of CD4 count, the risk of death was substantially higher for those with anemia.
Proper diagnosis is key, as meds are not the only cause of anemia. Others include opportunistic diseases (including MAC, tuberculosis, CMV colitis, cryptococcal meningitis and other fungal infections, parvovirus B-19, lymphoma, and Kaposi’s sarcoma), deficiencies of vitamin B-12 or folic acid, and HIV itself. And the latter is a catch-22—the drugs you’re taking may cause it, but leaving HIV untreated will let the virus impair the production of red blood cells. The answer for many is very pricey injections of recombinant human erythropoietin, termed Epoetin alpha (Procrit and Epogen), usually given three times per week, to boost red-blood-cell production. It will often resolve anemia quickly and return energy to your life.

Gas and Bloating
“Oops, I cleared the room again”

The odiferous intestinal gas and abdominal bloating that protease inhibitors can cause often continue for as long as the drugs are taken, but will usually “pass” quickly if the offending drugs are discontinued. When stopping is not an option, some HIV doctors have found that taking pancreatic enzymes (one or more, with every meal or snack) can often eliminate the problem. Make sure to choose a brand that contains lipase, the fat-digesting enzyme, since it appears to be the key. Your doc can prescribe Ultrase MT-20, making the cost reimbursable by insurance. The amino acid L-glutamine (5 to 10 grams per day) may also help by improving absorption of fat and preventing its passing into the colon undigested where it will be acted on by bacteria and create—you guessed it—stinky gas.

Hair Loss
“Who pulled the rug out from over me?”

Hair loss can be caused by many meds, particularly chemotherapy drugs, but for HIVers the most common cause is 3TC (Epivir). Too many users have reported finding clumps of hair peppering their pillows or clogging their drains every morning. And unfortunately, no one seems to have found a solution other than discontinuing the problematic drug. Even then, the return of the lost hair may be slow and incomplete. We wish we had better news. We don’t.

Life is sweet, these are not
Protease inhibitors have been tied to an increased incidence of glucose intolerance (the body’s inability to properly handle blood sugar) and insulin resistance (decreased sensitivity to insulin, the hormone that’s needed for the absorption of glucose into the body’s cells). When that process isn’t working properly, the glucose remains in the bloodstream, where it can damage blood vessels and ultimately cause diabetes, with complications that can include kidney failure, blindness and cardiovascular problems from top (strokes) to bottom (amputations) and in between (heart attacks). So far, the rate of diabetes among HIVers is relatively low, but researchers fear it will increase.

Recent studies show that Crixivan (indinavir), amprenavir (Agenerase) and ritonavir—and probably the other PIs—suppress insulin-stimulated glucose absorption. Older studies found that insulin resistance appears before lipo symptoms do. So some researchers predict that insulin resistance may occur much earlier and more widely than reported and could be one cause of lipodystrophy. While research on possible drug therapy continues, it couldn’t hurt to take the normal steps to boosting insulin sensitivity: regular progressive resistance exercise (such as weight training); weight loss in those who are significantly overweight; testosterone replacement in men; and a potent multivitamin/mineral that contains the B complex, antioxidants and minerals (especially chromium) that help maintain insulin sensitivity.
 
Kidney Stones
Rocks in a hard place

Kidney stones can develop in people taking Crixivan, especially if they drink too few fluids. Although the newer approaches that reduce Crixivan doses by combining it with ritonavir can lessen the likelihood of this problem, anyone on the drug should imbibe at least a couple of quarts of healthful liquids daily. More specifically, divide your body weight in half, and drink that many ounces of water, non-caffeinated teas, juices or broths every day. And remember that alcohol and caffeine are dehydrating and increase your need for the good fluids. Bottoms up!

Muscle Aches and Pains
Mama said there’d be days like this

Myopathy—the muscle problem that creates aches, pains and weakness—can be caused by AZT and maybe other nukes. While discontinuing the drug can often solve the problem, that’s not an option for those who need that class in their combos. And although aspirin and other over-the-counter pain meds may help, they usually don’t solve the problem. The amino acid L-carnitine (3,000 to 6,000 mg daily), however, may. In small studies, carnitine reversed myopathy and left those taking it feeling substantially better, possibly via its effects on reversing the nuke-caused mitochondrial dysfunction (see Body Distortions).

Nausea
Not-so-peaceful, queasy feelings

Nausea—that puking feeling—can be caused by antiretrovirals (AZT, 3TC, abacavir, ritonavir, saquinavir [Fortovase], Crixivan and amprenavir [Agenerase] are common causes), as well as other drugs including Bactrim (PCP prophylaxis), and will almost always vanish when the problematic drugs are discontinued. The exception can be when the liver has been damaged by the drugs, since that damage can result in long-term nausea. Supporting the liver is crucial to prevent this (see “Crossing the Liver,” page 62). When it’s not possible to stop drug culprits, there are many things that may help reduce queasiness.

First, consult your physician or pharmacist to determine whether taking the drug at a different time of day could help. Some drugs need to be downed with a full meal in order to avoid nausea, while for others, an empty stomach does the job. If your particular meds allow, making such adjustments can help.

Taking antinausea (anti-emetic) drugs can often reduce or eliminate this problem. Included on a long list are prochlorperazine (Compazine; usually given in doses of 10 mg, every six to eight hours), promethazine (Phenergan; given in doses of 25 to 50 mg, every four to six hours), trimethobenzamide hydrochloride (Tigan; in doses of 100 to 250 mg, three to four times per day; also via 200 mg suppositories or intramuscular injections, usually of 100 to 200 mg, three to four times per day), metoclopramide (Reglan; tablet or syrup, in 10 to 20 mg doses, three to four times per day), dronabinol (Marinol; synthetic marijuana capsules in doses of 2.5 to 10 mg, three times per day) and, last but definitely not least, the real deal, marijuana itself, used as needed (beware the paranoia, the price and the police). Powdered ginger root (two to three capsules before eating) or ginger tea (brewed from chopped fresh ginger root) are folk remedies.

Since med-induced nausea is particularly problematic at mealtime, anything that helps get food down is useful. Crunching down on dry, salty crackers or pretzels prior to eating and taking meds helps settle some stomachs. Sniffing grated lemon peel and drinking water with lemon in it just before eating can also help, as can drinking cool, carbonated beverages, especially gingerale. The whole-foods brands that contain a potent blast of ginger (like Reed’s Premium Ginger Brew) will work better than standard varieties. Substituting cool, bland foods for hot, spicy or greasy ones is often useful. Since maintaining your food and fluid intake is crucial for health, if the nausea waxes and wanes, down lots of fluids, protein and calories when you’re feeling better in order to make up for the times when you don’t.

Neuropathy
Stop working my nerves!

Neuropathy—the nerve damage that causes numbness, burning, tingling and pain in the hands, feet, arms and legs—is most often caused by d4T, ddC (Hivid) or ddI (Videx), as well as by metronidazole (Flagyl), thalidomide, isoniazid, vincristine, dapsone and alcohol. Less commonly, it can also stem from 3TC. It is extremely important that drugs causing neuropathy be stopped immediately after symptoms begin in order to prevent permanent problems. Doing so usually allows the pain and numbness to subside and eventually—up to several months later—stop.
Both large trials with diabetics and many anecdotal reports from HIVers have shown the usefulness of nutrient supplements for preventing or reversing neuropathy. The fatty acids alpha-lipoic acid (200 to 400 mg, three times daily) and gamma-linolenic acid (240 mg, twice daily) as well as the amino acid L-acetyl-carnitine (LAC; 500 to 1000 mg, three times daily) seem to be particularly useful. A small study showed that HIVers on the “d” drugs—ddI, ddC or d4T—have low levels of LAC, and that six months of supplementation improved both symptoms and nerve biopsy results, even without stopping the drugs. Also important is replenishing vitamin B-12 (1,000 micrograms from nasal gel, one to three times weekly) and vitamin B-6 (25 to 50 mg daily), taken with a B-complex supplement, since deficiencies of B vitamins, common in HIVers, can cause neuropathy.

Anything that reduces pressure on hypersensitive feet or hands can also help. This includes shortening walking distances, not standing for long periods, wearing loose-fitting shoes and socks, avoiding repetitive pressure on the hands, and soaking the feet or hands in ice water on a regular basis. Raising heels or hands off the mattress with a small pillow can help prevent increased pain while sleeping. Regular low-impact exercise may help by increasing circulation to the nerves. While one small trial found no benefit, many swear by acupuncture, with improvement often occurring with the first treatment, although repeated treatments may be necessary for long-term relief.

Pharmaceutical agents help some reduce pain, but they won’t stop numbness. For nocturnal pain, the standard recommendation is for oral amitriptyline (Elavil), beginning with low doses to minimize its own side effects—dry mouth, sedation, urinary retention and orthostatic hypotension (low blood pressure that can sometimes cause dizziness). A starting dose of 25 mg at bedtime is gradually increased to 75 mg (up to 150 mg if needed). Since it does have sedative effects, Elavil may be particularly useful when sleep problems accompany the neuropathy. For daytime pain, oral nortriptyline (Pamelor) is often advised since it is less sedating, with a starting dose of 10 mg daily, gradually increasing to 30 mg, three times daily. With both of these drugs, effective reduction of pain may not occur for a few weeks, so patience is required. (For more pharmaceutical options, see “Numb and Number,” POZ, January 1999.)

Night- and Daymares
Don’t turn out the lights!

Anxiety, depression, dizziness, insomnia, nervousness and nightmares are all possible side effects of certain HAART drugs. The cognitive problems caused by the NNRTI Sustiva (efavirenz) can occur both day (muddled thinking, paranoia and disorientation) and night (insomnia and, when you get to sleep, heebie-jeebie dreams). In many people, these problems disappear after several weeks on the drug, so waiting them out for at least a month is advisable—if you can. For others, they persist and, if the symptoms are unbearable, drug discontinuation is the only solution.

Crixivan and ddI can cause chronic anxiety in some users, which can remain until the drug is discontinued. Anti-anxiety meds or herbs such as kava kava can help. But two warnings: Long-term use of these meds is addictive; antidepressants may be a better choice. And combining anti-anxiety meds with kava kava is dangerous.

Occasionally, ddI can cause nervousness and sleeping difficulties. Abacavir can also give rise to restlessness and dizziness. Depression can develop from nevirapine (Viramune) and saquinavir. As with Sustiva, all of the above symptoms may disappear after weeks on the drug or may remain long-term, with drug discontinuation the only solution.

Pancreatitis
A punch in the gut

Pancreatitis is a potentially fatal inflammation of the pancreas, the organ that secretes enzymes (which go into the gut and help digest food) and insulin (which regulates the use of glucose, the cells’ source of energy). It can be caused by ddI, ddC, 3TC, d4T and Bactrim, as well as by high levels of blood fats, especially the sky-high triglycerides seen in many HAART-takers (for treatments see “Change of Heart,” page 60). Elevations in the level of the enzyme amylase can indicate pancreatitis. The standard North American treatment for this problem is usually just the immediate cessation of the problematic drug(s), along with bed rest and pain meds.

German researchers, however, have added another therapy that’s worth considering. Because high levels of pancreatic tissue–damaging free radicals (harmful molecules) are created in the early stages of pancreatitis, in various trials they gave selenium (in water-soluble form as sodium selenite), in doses of 500 mcg daily, often combined with vitamin E (1,600 international units daily) and sometimes other antioxidants (vitamin C and N-acetyl-cysteine, or NAC) immediately after a pancreatitis diagnosis. Death rates plummeted, and patients experienced faster recovery, less pain and shorter hospital stays. Immediate use of antioxidants would seem wise for anyone diagnosed with this problem, and long-term use of the nutrients might even help prevent the problem.

Last but not least, since pancreatitis may be tied to mitochondrial toxicity, the use of therapies that might counter that could be of value (see Body Distortions).

Skin Sins
Pretty petty? Don’t be rash

Rashes caused by the non-nukes nevirapine, delavirdine (Rescriptor) and Sustiva and the nuke abacavir are sometimes life-threatening and always annoying. Any rash that appears after beginning these drugs should prompt a quick visit to the doctor. If it’s drug-related and ignored, it could progress into a potentially fatal hypersensitivity reaction. In general, the only solution for severe skin reactions is discontinuation of the offending drug. Although some meds can be tried again (“rechallenged”) after a rash, usually at lower starting doses, this is not the case with abacavir, which must not be used again. The now-standard protocols for beginning with lower doses of certain non-nukes can help prevent this. Other drugs, including ddC and Bactrim, can also cause serious rashes.

Less serious rashes are a common occurrence that may be related to meds, although they can also be set off by many infections, so a full exam by an HIV-knowledgeable dermatologist is a must. Standard treatment is a locally applied cream, often one of the corticosteroid variety that suppresses inflammation.
 Long-term use, however, is inadvisable because these creams can create immune suppression when absorbed. Alternative practitioners have found that taking essential-fatty-acid supplements (several capsules daily of borage and flaxseed oils) can help, both by resupplying the fatty acids that are deficient in many HIVers and by providing an anti-inflammatory effect (see “Skin Deep,” page 78). Accompanying this with a potent multivitamin/mineral—to provide the vitamins A, B and E plus zinc that are necessary for overall skin health—can help ensure the presence of all key skin-nourishing nutrients. When dryness or itchiness is present, drinking plenty of fluids and applying any powerfully moisturizing cream can help. Two of the most effective are the over-the-counter Eucerin and Kiehl’s Crème D’Elegance Repairateur.

Another painful annoyance, cracked lips, seems to be caused most often by Crixivan. There have been anecdotal reports of many solutions, including vitamin E rubbed on the lips (break open a capsule), Diprolene (a prescription cream), Micatin cream (an over-the-counter antifungal), Desitin (diaper-rash cream), bag balm (available in pharmacies) and gallons of good old water.


KNOW THESE NUMBERS

It's time to watch more than your CD4 count and viral load. The
following tests can provide a report card on the damage that AIDS drugs may have done to your cells and organs. Ask your doctor every two to three months.

How's Your Liver?
ALT, AST, LDH, GGPT, ALP and bilirubin on your standard blood chemistry will show liver damage. Follow-up: A biopsy will show the kind, extent and location of the damage.

How Are My Kidneys?
Creatine and BUN on your standard blood chemistry and creatine clearance in a 24-hour urine collection will show kidney damage.

How Are My Blood  Cells?
Your red blood cell, white blood cell, neutrophils, platelets, hematocrit and hemoglobin on your standard blood cell count will show anemia, low platelets or low white-blood-cell counts from bone marrow suppression or other causes.

How’s My Heart?
Cholesterol, HDL cholesterol, LDL cholesterol, total cholesterol/HDL cholesterol ratio and triglycerides on your standard blood chemistry will show elevated blood fats that can lead to heart disease. Measuring high on the standard blood-pressure measure indicates heart disease.

Follow-up: High-sensitivity C-reactive protein, a blood test, is a strong predictor of heart disease. An ankle-brachial blood pressure index (ABI), which compares ankle and arm blood pressure, indicates increased risk of heart disease; a rest or stress electrocardiogram (ECG or EKG) can reveal a heart condition by measuring electrical activity. An echocardiogram (cardiac echo) can indicate a heart condition via ultrasound.

B-mode (ultrafast) ultrasound, which measures the thickness of key arteries, can indicate subclinical atherosclerosis. An electron-beam CT scan can detect calcium deposits within the coronary arteries. Cardiac magnetic resonance imaging (MRI) can provide a clear picture of arterial changes. An angiogram, an invasive procedure, creates a clear X-ray of the coronary arteries.

 



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