Diarrhoea

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• About diarrhoea
• Finding out the cause
• Treatment
• Diet
• Medications and supplements
• Slow release morphine sulphate

About diarrhoea

Most HIV medications list diarrhoea as a side effect. Ritonavir (Norvir) and other protease inhibitors are particularly associated with dirrhoea.

Diarrhoea remains one of the most common yet least talked about side effects.

HIV itself can also cause diarrhoea as can many HIV-related infections.

Most of us get diarrhoea at some point and having a lower CD4 count increases this risk. Diarrhoea can last for a few days, weeks, months or, in some cases, years.

Diarrhoea relates to increased frequency as well as looser and more watery consistency of stool.

It can be embarrassing to talk about diarrhoea or bowel habits. This may be one of the reasons that it is so badly managed.

However, it is important that diarrhoea is treated. Otherwise it can lead to dehydration, poor absorption of nutrients and drugs, weight loss and fatigue.

Finding out the cause

Often diarrhoea is temporary and may be due to starting or changing treatment. Symptoms often reduce within a few days or weeks as you get used to the HIV drugs.

In this case, short courses of anti-diarrhoea medications such as loperamide (Imodium) or diphenoxylate and atropine (Lomotil) can be effective.

If diarrhoea persists for more than a few days, and is not directly linked to starting a new combination, it is important to run tests to check that it is not being caused by bugs or parasite infections.

Non drug-related causes

If diarrhoea continues for more than a few days ask your doctor to arrange for a stool sample to be analysed to look for the cause. Some tests can take a couple of weeks for the results.

Depending on the severity and history of the symptoms and following examination, your doctor may prescribe a course of antibiotics along with anti-diarrhoea drugs to reduce the amount of times you need to go to the toilet.

If lab tests fail to show any bugs and if symptoms persist, then your doctor may want to perform an endoscopy. For this, a biopsy (a tiny piece of tissue) is sent for analysis in the laboratory. This can rule out other bowel problems such as colitis. As diarrhoea can be a symptom of other illnesses, it is important to run these tests.

If nothing shows up in these tests, then the treatment of the symptom itself becomes important.

Many HIV medications can cause diarrhoea and some are more problematic than others. If you are tolerating your combination generally, you may be able to manage diarrhoea with anti-diarrhoeal drugs or dietary changes, both of which are listed below.

Depending on your treatment options you can also look at changing the drug that is likely to be causing this.

Diet

• Many people have difficulty in digesting lactose, which is found in milk and dairy products. Reducing milk and dairy products in your diet can really help. Alternatives such as rice and soya milk do not contain lactose.
• ‘Rice water’ can help. Boil a small amount of rice in water for 30–45 minutes (or microwave for a shorter time), flavour with ginger, honey, cinnamon or vanilla when it cools, and then drink throughout the day.
• Eating less insoluble fibre can also help. Foods that contain insoluble fibre include vegetables, whole wheat breads and cereals, skins, fruit, seeds and nuts.
• Eat more soluble fibre. This is particularly helpful when watery stools are a problem as they help to absorb the excess water and bulk the stool. Soluble fibre is in white rice, pasta. Ispaghula (psyllium) husk (i.e Fybogel or Isogel) and oat bran tablets increase soluble fibre in your diet.
• Caffeine can cause the gut to speed up and result in more bowel movements. Caffeine is in coffee, tea and cola. Recreational drugs can have the same effect.
• Avoid high fat, greasy and high sugar foods.
• Don’t drink with your meals but make sure you take plenty of fluids between meals to replace the fluid being lost due to diarrhoea.
• Eat foods rich in potassium such as bananas, peaches, potatoes, fish and chicken. Potassium is lost when you have diarrhoea.
• Try eating live yoghurt to enhance the helpful bacteria in your gut. If you have a problem with dairy products then acidophilus can be taken in pill form. If your CD4 count is under 50 this may not be advisable.
• Whatever changes you make to your diet, make sure it remains balanced. Don’t live on just a few food products, as you will be missing out on essential vitamins and minerals. Excellent advice and support about diet can be obtained from the dietician at your treatment centre.

Medications and supplements

• Fluid and electrolyte replacement (such as dioralyte and sports rehydration solutions like Gatorade etc)
• Imodium (loperamide), Lomotil and codeine phosphate are the drugs most commonly prescribed for diarrhoea. They work by slowing gut motions and the speed that you process food, hopefully reducing the number of stools each day.
• Your doctor will normally prescribe these first and, for many people, these medications work well. It is important that the medications are taken regularly until the diarrhoea is well controlled. Start with low doses. If you are taking the maximum daily dose (for example 8 pills a day for Imodium) and you are still not getting the problem under control, go back to your doctor to try something else.
• Calcium supplements can help reduce diarrhoea associated with nelfinavir and possibly other protease inhibitors. The normal dose is 500mg twice a day and will help those who are avoiding dairy products as they are a major source of calcium in the diet.
• Glutamine has been used experimentally to try and improve bowel function. There is still some debate about the dosage – opinion ranges from 5g to 40g a day. It is available either as a powder that must be dissolved in water or a regular pill.
• Bulk forming laxatives are useful when watery stools are a problem. They absorb fluid and bulk out the stool – and lengthen the time the stool stays in the bowel. These drugs are generally taken following a meal and you should not drink for 30 minutes after taking them. Don’t take at the same time as meds. Brands include Fybogel, Isogel, Regulan, Celevac and Normacol.
• Studies on oatbran tablets taken by people with diarrhoea using protease inhibitors were successful and work on the same principle. The dose was 2–3 oatbran tablets before meals or after each protease inhibitor dose.

Treatments:

• diet changes
• dioralyte (electrolyte replacement)
• Imodium (loperamide) or Lomotil
• calcium supplements
• Ispaghula (psyllium husk or seeds)
• Glutamine
• MST (slow-release morphine sulphate)
• octreotide injections

As a last resort…

Slow release morphine sulphate (MST) or octreotide injections can be used if all the usual medications have failed to make a difference – although it is used less to control side effects and more to treat other causes of diarrhoea. The slow-release formulation of MST means that low doses of the drug are provided throughout the day. It comes in a wide range of strengths, each coloured differently, so you can be very careful about only taking the dose that you need.

The liquid formulation of morphine sulphate can be used for diarrhoea that occurs at specific times – ie in the hours after dosing.

MST works because one of the side effects of opiates is constipation, and it works by slowing down the gut.

Because it is an opiate, many doctors do not readily offer MST, so you may have to be persistent to get to use it. For some people it is the only thing that works – and even very low doses mean you can get back to a normal life.

How opiod anti-diarrhoeals work

i) Before opiates rapid bowel contractions prevent water being absorded. ii) Opiates slow bowel contractions allowing more water to be absorbed.

i) Before opiates rapid bowel contractions prevents water being absorbed

ii) Opiates slow bowel contractions allowing more water to be absorbed

How bulk-forming agents work

Bulk forming agents contain particles that absorb water and swell up making faeces firmer and more solid.

Bulk forming agents contain particles that absorb water and swell up making faeces firmer and more solid

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This is the web edition of the i-Base guide Avoiding & managing side effects. This guide is available in UK clinics. You can order free printed copies or download a PDF version (564 Kb). There are also several translations. Decisions relating to your treatment should always be taken in consultation with your doctor. Information in this guide is intended to support those discussions