Don't Miss HIV Patients' Alternative Medicine Use

SAN FRANCISCO — The use of complementary and alternative medicines is common but often overlooked among patients infected with HIV, Dr. Jason Tokumoto said at a meeting on HIV management sponsored by the University of California, San Francisco.

Studies have indicated that 70% of HIV-infected patients use some form of complementary or alternative medicine (CAM).

A survey of 1,675 HIV-infected patients found that the most commonly used CAM products included multivitamins (54% of patients), garlic (53%), massage (49%), and acupuncture (45%) (AIDS Care 2001;13:197–208).

Physicians are often unaware of the use of CAM products. “This can be a problem because in some cases these [complementary or alternative medicines] can actually be harmful,” said Dr. Tokumoto of the department of family and community medicine at UCSF.

In one study, 25% of the surveyed HIV-positive patients were using a CAM product that was potentially harmful, and one-third of these patients did not tell their clinicians about their CAM use (J. Aquir. Immune Defic. Syndr. 2003;33:157–65).

For example, St. John's wort, which may have some efficacy for depression, interacts with the cytochrome P-450 enzyme system and can thereby decrease indinavir trough blood levels by 81% and nevirapine levels by 21%.

St. John's wort should not be used with any protease inhibitor or nonnucleoside reverse transcriptase inhibitor, Dr. Tokumoto said.

Garlic, which many HIV patients use to improve lipid levels, should not be used with saquinavir. Garlic can reduce saquinavir blood levels by 51%, probably because it, too, is an inducer of the cytochrome P-450 system, he said.

CAM users tend to be women, be involved in medical decisions, have a negative attitude toward antiretroviral therapy, have been infected for a relatively long time, and have high income and education levels.

Dr. Tokumoto offered these comments about CAM uses and HIV:

▸ Herbals. Nothing known in herbal medicine or Chinese medicine has been shown to be effective in suppressing HIV or stimulating the immune system. A Cochrane review recently looked at nine randomized, placebo-controlled trials of eight herbal products in HIV patients. “What the authors concluded was that none of these herbs really worked,” Dr. Tokumoto said.

There has been debate over whether HIV patients should take echinacea, sometimes used to treat colds, because of concerns that long-term use could lead to immunosuppression.

▸ Micronutrients or vitamins. Studies suggest that most HIV-infected patients are not micronutrient deficient and not clinically vitamin deficient, although it has been reported that HIV-infected persons have low serum levels of vitamins A, E, B6, and B12.

But in one trial, researchers gave micronutrients or placebo to 40 HIV patients for 12 weeks, and found an increase in the mean number of CD4 cells in the micronutrient group and a decrease in the placebo group. There was no difference in viral load (J. Aquir. Immune Defic. Syndr. 2006;42:523–8).

“While these results look promising, this is a small study,” Dr. Tokumoto said.

Dr. Tokumoto said he often has his patients take a multivitamin, despite very limited supporting data and no evidence that supplementation increases CD4 counts or improves mortality.

Some vitamins and antioxidants such as riboflavin, thiamine, and vitamins C, E, and K may theoretically prevent lactacidemia caused by mitochondrial toxicity from nucleoside analogues.

But there have been no trials in HIV patients, and these substances have had only limited value in patients with congenital mitochondrial disease.

“There are scattered anecdotal reports of patients responding to some of these vitamins,” Dr. Tokumoto commented.

▸ L-carnitine. In an uncontrolled study of 21 HIV patients, administration of L-carnitine 1,500 mg twice daily for 6 months appeared to reduce nucleoside analogue-related neuropathy. Overall, 76% of the patients showed improvement (HIV Clin. Trials 2005;6:344–50).

▸ Lipodystrophy. No CAM is currently being investigated for lipodystrophy; however, in one 74-patient survey, 25% used vitamins, 23% used resistance exercise, 21% used specific diets, and some used meditation in an effort to reduce lipodystrophy. Only 37% told their physician they were using these modalities (J. Altern. Complement. Med. 2006;12:475–82).

▸ Hyperlipidemia. The supporting studies of garlic to lower lipid levels are compromised by their short duration and the different preparations used, according to Dr. Tokumoto.

Cholestin, which is produced by red yeast fermented on rice, contains natural statins. This substance has been shown to reduce LDL cholesterol and triglyceride levels by 20%–30%. But there are no studies in HIV patients, and no studies of the interactions with protease inhibitors.

Fish oil has also been shown to cause a decrease in patients' triglyceride levels.

▸ Milk thistle. Milk thistle could be attractive to HIV patients who are on antiretrovirals and/or coinfected with hepatitis B or C because its active ingredient, silymarin, may be hepatorestorative. At the dosages used, it probably does not interfere with the efficacy of protease inhibitors.

Although the data are inconclusive, “I do know some hepatologists who are prescribing milk thistle for their hepatitis C patients,” he said.

▸ Acupuncture. Acupuncture is widely used by HIV patients for pain and neuropathy. One study of 215 patients reported that neither acupuncture nor amitriptyline was more effective than placebo (JAMA 1998;280:1590–5). But most acupuncturists say that the procedure is difficult to study rigorously because treatment is highly individualized, Dr. Tokumoto said.

▸ Marijuana. Anywhere from 14% to 43% of HIV patients may use marijuana medicinally or recreationally. Because of the political climate, marijuana use has not been studied in clinical trials, but smoking marijuana over a short period has been shown not to affect CD4 cell counts, viral load, or antiretroviral levels, he said. Efavirenz use may cause positive results on marijuana drug tests, he added.

SAN FRANCISCO — The use of complementary and alternative medicines is common but often overlooked among patients infected with HIV, Dr. Jason Tokumoto said at a meeting on HIV management sponsored by the University of California, San Francisco.

Studies have indicated that 70% of HIV-infected patients use some form of complementary or alternative medicine (CAM).

A survey of 1,675 HIV-infected patients found that the most commonly used CAM products included multivitamins (54% of patients), garlic (53%), massage (49%), and acupuncture (45%) (AIDS Care 2001;13:197–208).

Physicians are often unaware of the use of CAM products. “This can be a problem because in some cases these [complementary or alternative medicines] can actually be harmful,” said Dr. Tokumoto of the department of family and community medicine at UCSF.

In one study, 25% of the surveyed HIV-positive patients were using a CAM product that was potentially harmful, and one-third of these patients did not tell their clinicians about their CAM use (J. Aquir. Immune Defic. Syndr. 2003;33:157–65).

For example, St. John's wort, which may have some efficacy for depression, interacts with the cytochrome P-450 enzyme system and can thereby decrease indinavir trough blood levels by 81% and nevirapine levels by 21%.

St. John's wort should not be used with any protease inhibitor or nonnucleoside reverse transcriptase inhibitor, Dr. Tokumoto said.

Garlic, which many HIV patients use to improve lipid levels, should not be used with saquinavir. Garlic can reduce saquinavir blood levels by 51%, probably because it, too, is an inducer of the cytochrome P-450 system, he said.

CAM users tend to be women, be involved in medical decisions, have a negative attitude toward antiretroviral therapy, have been infected for a relatively long time, and have high income and education levels.

Dr. Tokumoto offered these comments about CAM uses and HIV:

▸ Herbals. Nothing known in herbal medicine or Chinese medicine has been shown to be effective in suppressing HIV or stimulating the immune system. A Cochrane review recently looked at nine randomized, placebo-controlled trials of eight herbal products in HIV patients. “What the authors concluded was that none of these herbs really worked,” Dr. Tokumoto said.

There has been debate over whether HIV patients should take echinacea, sometimes used to treat colds, because of concerns that long-term use could lead to immunosuppression.

▸ Micronutrients or vitamins. Studies suggest that most HIV-infected patients are not micronutrient deficient and not clinically vitamin deficient, although it has been reported that HIV-infected persons have low serum levels of vitamins A, E, B6, and B12.

But in one trial, researchers gave micronutrients or placebo to 40 HIV patients for 12 weeks, and found an increase in the mean number of CD4 cells in the micronutrient group and a decrease in the placebo group. There was no difference in viral load (J. Aquir. Immune Defic. Syndr. 2006;42:523–8).

“While these results look promising, this is a small study,” Dr. Tokumoto said.

Dr. Tokumoto said he often has his patients take a multivitamin, despite very limited supporting data and no evidence that supplementation increases CD4 counts or improves mortality.

Some vitamins and antioxidants such as riboflavin, thiamine, and vitamins C, E, and K may theoretically prevent lactacidemia caused by mitochondrial toxicity from nucleoside analogues.

But there have been no trials in HIV patients, and these substances have had only limited value in patients with congenital mitochondrial disease.

“There are scattered anecdotal reports of patients responding to some of these vitamins,” Dr. Tokumoto commented.

▸ L-carnitine. In an uncontrolled study of 21 HIV patients, administration of L-carnitine 1,500 mg twice daily for 6 months appeared to reduce nucleoside analogue-related neuropathy. Overall, 76% of the patients showed improvement (HIV Clin. Trials 2005;6:344–50).

▸ Lipodystrophy. No CAM is currently being investigated for lipodystrophy; however, in one 74-patient survey, 25% used vitamins, 23% used resistance exercise, 21% used specific diets, and some used meditation in an effort to reduce lipodystrophy. Only 37% told their physician they were using these modalities (J. Altern. Complement. Med. 2006;12:475–82).

▸ Hyperlipidemia. The supporting studies of garlic to lower lipid levels are compromised by their short duration and the different preparations used, according to Dr. Tokumoto.

Cholestin, which is produced by red yeast fermented on rice, contains natural statins. This substance has been shown to reduce LDL cholesterol and triglyceride levels by 20%–30%. But there are no studies in HIV patients, and no studies of the interactions with protease inhibitors.

Fish oil has also been shown to cause a decrease in patients' triglyceride levels.

▸ Milk thistle. Milk thistle could be attractive to HIV patients who are on antiretrovirals and/or coinfected with hepatitis B or C because its active ingredient, silymarin, may be hepatorestorative. At the dosages used, it probably does not interfere with the efficacy of protease inhibitors.

Although the data are inconclusive, “I do know some hepatologists who are prescribing milk thistle for their hepatitis C patients,” he said.

▸ Acupuncture. Acupuncture is widely used by HIV patients for pain and neuropathy. One study of 215 patients reported that neither acupuncture nor amitriptyline was more effective than placebo (JAMA 1998;280:1590–5). But most acupuncturists say that the procedure is difficult to study rigorously because treatment is highly individualized, Dr. Tokumoto said.

▸ Marijuana. Anywhere from 14% to 43% of HIV patients may use marijuana medicinally or recreationally. Because of the political climate, marijuana use has not been studied in clinical trials, but smoking marijuana over a short period has been shown not to affect CD4 cell counts, viral load, or antiretroviral levels, he said. Efavirenz use may cause positive results on marijuana drug tests, he added.

SAN FRANCISCO — The use of complementary and alternative medicines is common but often overlooked among patients infected with HIV, Dr. Jason Tokumoto said at a meeting on HIV management sponsored by the University of California, San Francisco.

Studies have indicated that 70% of HIV-infected patients use some form of complementary or alternative medicine (CAM).

A survey of 1,675 HIV-infected patients found that the most commonly used CAM products included multivitamins (54% of patients), garlic (53%), massage (49%), and acupuncture (45%) (AIDS Care 2001;13:197–208).

Physicians are often unaware of the use of CAM products. “This can be a problem because in some cases these [complementary or alternative medicines] can actually be harmful,” said Dr. Tokumoto of the department of family and community medicine at UCSF.

In one study, 25% of the surveyed HIV-positive patients were using a CAM product that was potentially harmful, and one-third of these patients did not tell their clinicians about their CAM use (J. Aquir. Immune Defic. Syndr. 2003;33:157–65).

For example, St. John's wort, which may have some efficacy for depression, interacts with the cytochrome P-450 enzyme system and can thereby decrease indinavir trough blood levels by 81% and nevirapine levels by 21%.

St. John's wort should not be used with any protease inhibitor or nonnucleoside reverse transcriptase inhibitor, Dr. Tokumoto said.

Garlic, which many HIV patients use to improve lipid levels, should not be used with saquinavir. Garlic can reduce saquinavir blood levels by 51%, probably because it, too, is an inducer of the cytochrome P-450 system, he said.

CAM users tend to be women, be involved in medical decisions, have a negative attitude toward antiretroviral therapy, have been infected for a relatively long time, and have high income and education levels.

Dr. Tokumoto offered these comments about CAM uses and HIV:

▸ Herbals. Nothing known in herbal medicine or Chinese medicine has been shown to be effective in suppressing HIV or stimulating the immune system. A Cochrane review recently looked at nine randomized, placebo-controlled trials of eight herbal products in HIV patients. “What the authors concluded was that none of these herbs really worked,” Dr. Tokumoto said.

There has been debate over whether HIV patients should take echinacea, sometimes used to treat colds, because of concerns that long-term use could lead to immunosuppression.

▸ Micronutrients or vitamins. Studies suggest that most HIV-infected patients are not micronutrient deficient and not clinically vitamin deficient, although it has been reported that HIV-infected persons have low serum levels of vitamins A, E, B6, and B12.

But in one trial, researchers gave micronutrients or placebo to 40 HIV patients for 12 weeks, and found an increase in the mean number of CD4 cells in the micronutrient group and a decrease in the placebo group. There was no difference in viral load (J. Aquir. Immune Defic. Syndr. 2006;42:523–8).

“While these results look promising, this is a small study,” Dr. Tokumoto said.

Dr. Tokumoto said he often has his patients take a multivitamin, despite very limited supporting data and no evidence that supplementation increases CD4 counts or improves mortality.

Some vitamins and antioxidants such as riboflavin, thiamine, and vitamins C, E, and K may theoretically prevent lactacidemia caused by mitochondrial toxicity from nucleoside analogues.

But there have been no trials in HIV patients, and these substances have had only limited value in patients with congenital mitochondrial disease.

“There are scattered anecdotal reports of patients responding to some of these vitamins,” Dr. Tokumoto commented.

▸ L-carnitine. In an uncontrolled study of 21 HIV patients, administration of L-carnitine 1,500 mg twice daily for 6 months appeared to reduce nucleoside analogue-related neuropathy. Overall, 76% of the patients showed improvement (HIV Clin. Trials 2005;6:344–50).

▸ Lipodystrophy. No CAM is currently being investigated for lipodystrophy; however, in one 74-patient survey, 25% used vitamins, 23% used resistance exercise, 21% used specific diets, and some used meditation in an effort to reduce lipodystrophy. Only 37% told their physician they were using these modalities (J. Altern. Complement. Med. 2006;12:475–82).

▸ Hyperlipidemia. The supporting studies of garlic to lower lipid levels are compromised by their short duration and the different preparations used, according to Dr. Tokumoto.

Cholestin, which is produced by red yeast fermented on rice, contains natural statins. This substance has been shown to reduce LDL cholesterol and triglyceride levels by 20%–30%. But there are no studies in HIV patients, and no studies of the interactions with protease inhibitors.

Fish oil has also been shown to cause a decrease in patients' triglyceride levels.

▸ Milk thistle. Milk thistle could be attractive to HIV patients who are on antiretrovirals and/or coinfected with hepatitis B or C because its active ingredient, silymarin, may be hepatorestorative. At the dosages used, it probably does not interfere with the efficacy of protease inhibitors.

Although the data are inconclusive, “I do know some hepatologists who are prescribing milk thistle for their hepatitis C patients,” he said.

▸ Acupuncture. Acupuncture is widely used by HIV patients for pain and neuropathy. One study of 215 patients reported that neither acupuncture nor amitriptyline was more effective than placebo (JAMA 1998;280:1590–5). But most acupuncturists say that the procedure is difficult to study rigorously because treatment is highly individualized, Dr. Tokumoto said.

▸ Marijuana. Anywhere from 14% to 43% of HIV patients may use marijuana medicinally or recreationally. Because of the political climate, marijuana use has not been studied in clinical trials, but smoking marijuana over a short period has been shown not to affect CD4 cell counts, viral load, or antiretroviral levels, he said. Efavirenz use may cause positive results on marijuana drug tests, he added.