Uncomplementary Therapies
Most people living with HIV use complementary medicines at some time, but
new research suggests some of us who swear by ‘natural’ remedies
may be playing Russian roulette with our HIV meds. Robert Fieldhouse
reports
As
many as one in ten patients at HIV clinics across London are taking complementary
or alternative treatments that may be detrimental to their health.
This was the startling finding of new pharmacist-led research paper presented
at the World Aids Meeting this summer.
The questionnaire-based study of almost 300 people living with HIV on antiretroviral
treatments found many took alternative treatments that can cause unpleasant
side effects in people with lowered immunity. More worryingly, some were taking
therapies known to interact with HIV treatments.
The UK complementary and alternative remedies market is worth an estimated
£200 million pounds a year so the commercial pressure on people to buy
them is huge.
And people with HIV are not immune to this pressure. It is common for people
living with HIV to use alternative treatments on top of their meds without
telling their doctor or pharmacist.
But the reality is many ‘natural’ therapies have the potential
to interact with antiretroviral drugs and compromise their effectiveness by
reducing drug levels in the blood or exacerbating side effects by boosting
their levels.
This recent study is interesting because it was led by a pharmacist but involved
a multi-disciplinary team including specialist dietitians, researchers in
psychological medicine, HIV doctors and a consultant psychiatrist.
Almost two-thirds of those surveyed were taking herbal or alternative remedies
and a little over a third were using physical therapies such as massage. One
in ten (11 per cent) were advised to stop taking the complementary therapies;
eight per cent because of potentially dangerous side effects from echinacea
and three per cent because of interactions which weaken the effectiveness
of their HAART regimen. The supplements most likely to reduce effectiveness
of HIV drugs were garlic, kava kava and St John’s wort.
Worst
offenders
Barts and the London pharmacist David Ladenheim, who led the study, told PN:
“We tried to be pragmatic in our approach, to gather evidence to either
support the use of alternative treatments or to help us advise against their
use.
“Kava kava was withdrawn from the UK market following studies showing
its use contributed to increased rates of liver toxicity.
“The World Health Organisation has issued guidance on echinacea advising
against its use by anyone living with HIV regardless of whether they are on
antiretroviral treatment or not.
“This is because it can boost the number of HIV infected immune cells
which may lead to an increase in HIV viral load.
“Fairly substantial data exist on the impact of a component of garlic
called allicin and its potential to decrease levels of NNRTIs (non-nukes)
and protease inhibitors. We suggest it is best avoided in people on HAART.”
One in seven people included in the study were advised to use complementary
products with caution, two per cent of because of the potential for side effects
and 12 per cent because of the risk of an interaction with their HIV therapy.
“We recognise the psychological benefit of people taking alternative
treatments; they feel are beneficial. We don’t wish to put people off,
rather help people make more informed choices around their use of such products.
“A few patients in our study were taking glucosamine, but this did not
appear to have an effect on antiretrovirals. Gingko Biloba, on the other hand,
may potentially reduce levels of NNRTIs and protease inhibitors.”
Milk thistle and St John’s wort
Many people concerned about their livers advocate using milk thistle, despite
patchy evidence regarding its effectiveness, as Ladenheim explains:
“There is currently no high quality evidence to suggest milk thistle
has any beneficial effect on the liver. In addition, there is some evidence
that it may alter the metabolism and elimination of certain drugs including
PIs and NNRTIs.
“In such circumstances, weighing up the risks and benefits of milk thistle,
I would strongly urge an HIV positive patient currently taking a PI or NNRTI
not to take it.”
Ladenheim’s research clearly underlines the importance of doctors and
pharmacists being aware of complementary medicine use by their patients as
well as the need for people living with HIV to discuss the use of such products
with their clinic.
Several years ago researchers showed that people taking the natural antidepressant
St John’s wort alongside combination antiretroviral treatments were
more likely to experience treatment failure. This was as a result of a drug
interaction between St John’s wort and non-nukes or protease inhibitors
which resulted in a lower level of the HIV drugs. This is perhaps the most
well-known interaction between an alternative treatment and antiretroviral
drugs.
Telling
your doc
Only half of the study participants taking complementary therapies had actually
discussed their use with a member of their healthcare team.
This has prompted Ladenheim to urge people on antiretrovirals to let their
doctor or pharmacist know what products they are using. It also provides essential
safety information to pharmacists.
Rosy Weston, principal HIV/GUM pharmacist at St Mary’s Hospital, London,
told PN that they routinely asked all patients about any medicines they were
taking in addition to their prescription medications. They also ask about
drug allergies.
“We sometimes need to prompt patients by asking them if they are taking
any herbal preparations, over-the-counter medicines, as well as medicines
prescribed by their GPs.”
This information is recorded on the prescription so the pharmacist clinically
‘screening’ the ‘script has the full information to assess
its safety. This practice has been adopted throughout the pharmacies at St
Mary’s.
“Where it gets tricky is assessing potential interactions or additive
side effects. There are very few referenced or even reliable sources for information
and often the pharmacist will need to go back to basic pharmaceutical principals
to make a decision.”
Potato warning
A few weeks after the London research was presented in Toronto, a similar
message was delivered to nutritionists in Aids-hit South Africa.
Use of muthi, traditional medicine, in South Africa is widespread and even
advocated by ministers as an ‘alternative’ or adjunct to antiretrovirals.
But now evidence is emerging that some muthi could harm those lucky enough
to be on HIV therapy. South African doctor Kas Kasongo, an educator at the
Nelson Mandela Metropolitan University, issued a warning to nutritionists
that use of the African potato (Sutherlandia) could be harmful.
Kasongo, coordinator of the HIV Clinician Society of Mandela Bay, told a congress
of nutritionists: “While some extracts of the African potato in purified
forms are helpful, some are harmful as they suppress the bone marrow.
“In some cases this traditional medicine has the potential to interfere
with certain types of antiretrovirals, lowering their effectiveness by up
to 80 per cent.”
He said 80 per cent of Africans culturally preferred traditional medicine,
as they viewed it as holistic, personalised, affordable and easily available.
But he warned that more reliable information about the healing powers of herbs
and nutrition were needed so it could be “used with confidence”.
Another study from Stellenbosch University found excess consumption of garlic
and beetroot was also problematic.
Roy Kennedy, author of the South African national guidelines on nutrition
for people living with TB, HIV/Aids, concluded: “Eating large amounts
of garlic while on some kinds of ARVs can make treatment up to 50 per cent
less effective.”
Multivits
Growing evidence suggests people living with HIV require more vitamins and
minerals than the recommended daily allowance. Work by Dr Jon Kaiser in the
US suggests their use may have a potential role in lengthening the time someone
can stay off therapy.
But even here we need to be careful because research shows even having too
much of one nutrient could be detrimental.
For instance, too much zinc accelerates HIV disease and high levels of vitamin
A have also been shown to be problematic.
But it’s not all doom and gloom. Research from Nigeria suggests that
taking 200mg of selenium as well as antiretroviral therapy led to greater
CD4 cell increases than taking antiretroviral therapy of d4T, 3TC and nevirapine
alone.
The study looked at 340 people with advanced HIV, (CD4 cell counts below 50)
and found those on selenium plus HAART gained more than twice the number of
CD4 cells over 72 weeks (120 vs 50 cells) compared with people receiving anti-
retroviral therapy alone.
People taking selenium developed fewer opportunistic infections, gained more
weight and their haemoglobin increases were three times greater than the increases
seen with HAART alone.
Safety
and lack of evidence
For many years doctors in the UK have been prescribing omega-3 fish oils for
people with elevated triglyceride levels - so a spoonful of cod liver oil
a day appears unlikely to do you any harm. But pharmacists generally prefer
caution in the absence of evidence.
“The concept of assuming that no information or reported ill-effects
means an alternative treatment is safe for people on HAART is not a safe approach
to take.
“If we are in any doubt, we recommend patients beginning antiretroviral
therapy or those who have a detectable/borderline viral load should be extremely
cautious and seek advice from their clinic pharmacist,” Rosy Weston
explains.
“Our clinicians do routinely ask about complementary and alternative
medicines, and this is nearly always raised at our meetings if a person gets
an unexpected viral load result. Our prescriptions for home delivery also
have a section for the clinician to complete on additional medicines.”
If in any doubt about any alternative remedies you are taking, consult your
doctor and your pharmacist. Alternative therapies are often costly and generally
less available on the NHS than they used to be, so you could be throwing your
money away as well as the chance of a sustained response to antiretroviral
therapy.
