• E-mail
• Print
• Comment
• Font Size
• Digg
• del.icio.us
• Discuss article

What is Your Patient Taking? Dietary Supplements in an HIV-Positive Patient

Posted on: Saturday, 8 October 2005, 03:00 CDT

By Browne, Rita; Boag, Fiona

Summary: We report on an HIV-positive individual who developed a biochemical hepatitis likely to be due to excessive intake of dietary supplements, highlighting the need for clinicians to be vigilant over their use.

Keywords: dietary supplements, HIV positive, complementary medicine

Introduction

Dietary supplements are frequently taken as a part of a normal diet and physicians are often unaware of this. The literature on supplements for HIV-positive individuals is extensive, but evaluation of efficacy, recommended dose, side effects and interactions is sparse; thus it is difficult to advise patients on their use. We report on a patient who developed a biochemical hepatitis while taking a concoction of supplements in the above- recommended dosage to highlight what may become a frequently seen complication.

Case history

The case is that of a 33-year-old man, diagnosed HIV-positive in 1999. At HIV diagnosis his CD^sub 4^ count was 678 10^sup 9^/mL and viral load 28,792 (4.6 log^sub 10^) copies/mL (Chiron bDNA assay). He was antiretroviral nave and attended an HIV clinic for three- monthly follow-up.

He had had moderately severe acne for two years and, on referral to the dermatologists, was treated with a course of roaccutane with a good response. A recurrence of acne was treated with erythromycin for three months. While on erythromycin, there was no improvement in his acne and his liver function tests (LFTs) showed a mild increase in alanine transaminase (ALT) (49 U/L). Erythromycin was stopped; however, his ALT continued to increase (to 76 U/L), and there was concern about restarting roaccutane; so he was given topical isotrexin gel and cleansing lotions.

Investigations into the cause of his raised ALT were unhelpful; syphilis and hepatitis B and C serology were negative (non- responder to hepatitis B vaccine in the past) and he was vaccinated against hepatitis A. Serum iron studies were normal and his alcohol consumption was nil. Direct questioning elicited a history of anabolic steroid use to enhance musculature. It was thought that this was precipitating the flare-up in his acne and ALT and he was advised to stop. His acne resolved and his ALT fell to 44 U/L.

Three months later, he developed a persistent eczematous rash over his eyes and flexural surfaces and general lethargy. He now had symptomatic HIV infection (despite a CD4 count of 380 10^sup 9^/ mL) and HAART was offered to improve his skin and general wellbeing. However, he declined and decided to try a 'healthy diet'.

After three months of this, he reported he was 'exceedingly well and happy'. However, blood tests taken at this clinic visit showed that his ALT had risen to 189 U/L, viral load from 176,576 (5.3 log^sub 10^) to 500,000 (5.7 log^sub 10^) copies/mL and CD^sub 4^ count was 516 10^sup 9^/mL. He was phoned and he revealed that his 'new diet' included dietary supplements. He was asked to stop the supplements and return for review and repeat blood tests. Two weeks later, his ALT was 87 U/L, his CD4 count had dropped to 339 10^sup 9^/mL and his viral load was 246,652 (5.4 log^sub 10^) copies/mL. Hepatitis and syphilis serology were unchanged as was his alcohol consumption. He had not restarted anabolic steroids.

He brought all his supplements into the clinic: 13 in total; lecithin 3600 mg OD (3 recommended daily allowance [RDA]), omega-3 fish oil 700 mg TDS, acidophylis (3 RDA), betacarotene 15 mg OD, echinacea 80 drops BD (8 RDA), vitamin C 5000 mg OD (67 RDA), L- methionine 500 mg OD, multi-vitamins 3 OD (3 RDA), vitamin B100 one OD, amino 75 one OD, solidago 30 drops OD, milk thistle 30 drops OD (5 RDA) and enzyme digest. In addition, he ate fruit 3 times a day, vegetables twice and juiced vegetable once a day. He was spending 200 per month on supplements. He was advised to continue only omega- 3 but reduced to twice a day to help his skin. A month later his ALT was 51 U/L, CD^sub 4^ 357 10^sup 9^/L and viral load 375,267 (5.6 log^sub 10^) copies/mL. Five months after reducing his dietary supplements, his CD4 count is 349 10^sup 9^/mL, viral load is 135,961 (5.1 log^sub 10^) copies/mL and ALT 30 U/L.

Figure 1 Changes in alanine transaminase in relation to drug therapy CAM=complementary and alternative medicine

Our patient was asymptomatic and the abnormal hepatic function was only detected due to monitoring since the increase in ALT while he was taking erythromycin. No other cause for abnormal liver function tests was found and it resolved on withdrawal of supplements. Figure 1 demonstrates the changes in his ALT.

Discussion

An anonymous questionnaire survey of the use of complementary and alternative medicine (CAM) in HIV-positive individuals found that, between 1998 and 1999, 63% of patients surveyed (total: 899) were taking vitamins or minerals either with or without HAART.1 This was an increase from 58% (total:1167) of individuals reported in the 1996-1997 survey (prior to the widespread use of HAART); P = 0.06. The use of homeopathy and herbal products also increased over the same time period. In multiple regression analysis, a longer time since HIV diagnosis, having a higher education level and a lower CD^sub 4^ count were associated with use of CAM.1

Observational studies have demonstrated that micronutrient deficiencies in HIV-positive individuals are associated with faster progression and mortality, possibly through increased oxidative stress and viral replication or circulating T-lymphocyte depletion. Randomized placebo-controlled studies of the effect of micronutrient supplementation in HIV-positive individuals have had contrasting results, some of which we have summarized.

Earlier small studies did not demonstrate a significant improvement in immunological markers or clinical status between selenium, vitamin A, E and C, arginine, omega-3 fatty acids supplementation and placebo.2 More recently, vitamin E and C supplements have been demonstrated to reduce oxidative stress and produce a trend towards a reduction in viral load (not statistically significant).3 A Tanzanian study of 1075 women showed that multivitamin supplements given during pregnancy led to a significant increase in CD4, CD8 and CD3 and reduced neonatal morbidity.4

Four hundred and eighty-one individuals in Thailand (CD4 count of 50-550 10^sup 6^) were randomized to receive supplements or placebo.5 Supplements consisted of 21 micronutrients taken in above RDA. At 48 weeks the mortality was 5% (23), and was significantly higher in individuals on placebo with CD4 <200 especially if <100; mortality hazard ratio 0.37, P = 0.052 and 0.26, 0.03, respectively. There was no significant difference in CD4 or viral load between the arms.

For patients on HAART, the use of CAM is even more worrying because of the interactions with herbal medicines and HAART. St John's wort and echinacea interact with cytochrome P450 3A4 and co- administration with protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) is contraindicated.6 Complex interactions between garlic supplements and milk thistle; and PIs and NNRTIs may affect the efficacy of the latter. A low perception of possible adverse effects of complementary therapies and their interaction with HAART has been documented in current users.7 Patients may not disclose the use of CAM to their physician because they fear that they may not approve.

Our patient was spending a lot of money on supplements and high expenditures have been reported in studies (average euro100 per month1 or US$938 per annum8). Because of the chronic nature of HIV infection, spending such large amounts on supplements is an added financial burden most can ill afford.

Conclusion

We highlight this case to emphasize the need for physicians to clarify what other medication their patients may be taking. Multiple micronutrient supplements may enhance survival in patients with CD4 <200, in the presence of deficiency, and may have important implications especially in developing countries. However, in the presence of a normal diet they are of debatable benefit.

There are dangers associated with excessive intake of dietary supplements and interactions with conventional medications are largely unknown. Without dietary analysis patients may accidentally overdose, as many foods are supplemented. Research is needed as patients with chronic illness often use supplements.

References

1 Colebunders R, Dreezen C, Florence E, Pelgrom Y, Schrooten W. The use of complimentary and alternative medicine by persons with HIV infection in Europe. Int J STD AIDS 2003;14:672-1

2 Ozsoy M, Ernst E. How effective are complimentary therapies for HIV and AIDS? A systematic review. Int J STD AIDS 1999;10:629-35

3 Allard J, Aghdassi E, Chau J, et al. Effects of vitamin E and C supplementation on oxidative stress and viral load in HIV-infected subjects. AIDS 1998;12:1653-9

4 Fawzi W, Msamanga G, Spiegelman D, et al. Randomised trial of effects of vitamin supplements on pregnancy outcomes and T cell counts in HIV-1 infected women in Tanzania. Lancet 1998;351:1477-82

5 Jiamton S, Pepin J, Suttent R, et al. A randomised trial of the impact of multiple micronutrient supplementation on mortality among HIV-infected individuals living in Bangkok. AIDS 2003;17:2461-9

6 Website [www.hiv-drug interactions.org]

7 Agnoletto V, Chiaffarino F, Nasta P, Ro\ssi R, Parazzini F. Reasons for complementary therapies and characteristics of users among HIV-infected people. Int J STD AIDS 2003;14:482-6

8 Fairfield KM, Eisenberg DM, Davis RB, Libman H, Phillips RS. Patterns of use, expenditures, and perceived efficacy of complimentary and alternative therapies in HIV-infected patients. Arch Intern Med 1998;158:2257-64

Rita Browne DipGUM MRCP and Fiona Boag FRCP

GU/HIV Medicine, St Stephens Centre, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK

Correspondence to: Dr R Browne

Email: ritabrowne@doctors.org.uk

Copyright Royal Society of Medicine Press Ltd. Sep 2005

Source: International Journal of STD & AIDS

More News in this Category