Herbs (Additional PLUS Reading Materials)
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  • 1. HERBS, SUPPLEMENTS AND HIV DISEASE  PUBLISHED BY issues to consider when deciding to use herbs, vitamins and nutritional supplements Vitamins, supplements and herbs have long been used by people living with HIV to help manage the side e ects of their therapies or improve their gen- JANUARY 2005 eral health. In fact, studies suggest that almost 70% of people with HIV and about half the general population use some form of complementary therapy. e most common ones are massage and acupuncture. Unfortunately, not many of these have been studied in some food for thought when making decisions about people with HIV. ey have not been studied to see how using them. Promoters of supplements and herbs are they interact with common medications or whether o en the rst to criticize prescription drugs as the they add to the overall bene ts of anti-HIV therapy. products of “big business.” However, supplements are Recently, several reports have questioned the safety of themselves part of a huge industry—with annual sales some of these therapies in HIV and other diseases. of around $20 billion. is publication highlights some e intent of this publication is not to discourage emerging concerns about using various therapies and using complementary therapies, but rather to supply ways to limit the possible risks when using them.WHAT’S INSIDEA little background on supplements: 2; What about side e ects?: 2; Drug interactions: 3; Talking with your doctor: 4; Conclusion: 4; Buyer beware!:5; Vitamins and potential side e ects: 5; Herbal side e ects chart: 6–7; NIH study cautions use of St. John’s Wort with anti-HIV drugs: 8; Vitamin Aand anti-HIV drug interactions: 8; Selenium and HIV: 9; Amounts of selenium in various foods:: 10; Vitamin E, vitamin A and anti-HIV therapies:10; Vitamin supplements and HIV in women: 11; Zinc de ciencies and HIV: 12.© PROJECT INFORM 1375 MISSION STREET SAN FRANCISCO, CA 94103 2621 415 558 8669 FAX 415 558 0684 SUPPORT PROJECTINFORM.ORG WWW.PROJECTINFORM.ORG
  • 2. a little background on supplements Under current law, vitamins, supplements and herbs do People should be aware of these things and take meas- not have to be evaluated by any regulatory agency, like the ures to reduce their risk of buying contaminated prod- Food and Drug Administration (FDA), prior to their sale. ucts or ones without active ingredients. ey can do this All they need to do is assert that the product is “generally by seeking out reputable sellers. Seek guidance from a regarded as safe.” What this means is that studies are not trained alternative medicine practitioner, like an herbal- required to show the e ectiveness and safety of these prod - ist or nutritionist who specializes in HIV, and gather ucts. is leaves the consumer with little or no meaning ful information about the products you’re considering. information about their bene ts or side e ects. Only taking the word of people selling the products does Some manufacturers vaguely refer to “studies” in their not guarantee accurate information. literature, but these are seldom more than very small, On their packages and even their websites, some uncontrolled studies. Also, these products do not have to manufacturers claim their products have been tested for be made according to the same Good Manufacturing Prac- active ingredients. Do a little research and see what you tices established for making prescription meds. As a result, can learn. For example, some publications, like Con- these products vary widely in terms of their active ingre- sumer Reports and other groups like www.consumerlab. dients, and even between batches of the same product. In com, sometimes test supplements and list what is found fact, studies show that some products on the market today in various brands. Even this, however, doesn’t tell you contain no active ingredients whatsoever. whether you’ll bene t from using the product. Herbal supplements can actually contain danger- Generally, if a company shows integrity in some of ous chemicals, like arsenic and lead—both potentially its products tested by consumer groups, it’s a reasonable deadly. Still others actually contain prescription meds. sign that they maintain similar standards for their other However, the best manufacturers make a serious e ort products. According to researchers who evaluate these to deliver the real product in the amounts claimed. But therapies, the quality products that undergo evaluation due to the lack of industry regulations, there’s no simple by the manufacturer are, in general, not the ones you’ll 2 way to know who is telling the truth. nd at your average grocery store or pharmacy.HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORM what about side effects? The biggest myth about complementary therapies is that they’re not toxic. Many people believe that because something is “natural” or sold over the counter that it doesn’t have side effects. To the contrary, many people with HIV experience side effects from complementary therapies. For example, Chinese herbal remedies that contain deer antler can cause nausea, diarrhea and other stomach upset. One man stopped all his anti-HIV meds to try to determine which had upset his stomach and quality of life. It turned out that when he stopped his herbal therapy (with deer antler), his problems cleared. It wasn’t the anti-HIV drugs causing the problems at all. High doses of vitamin C can cause severe diarrhea. Taking too many B-6 vitamins can lead to a complication that lands one in the hospital, and excessive levels of vitamin A can be highly toxic to the liver. These examples illustrate the need to be cautious when adding large doses of vitamins to your diet. Side effects from using herbs, vitamins and supplements may not reveal themselves immediately. It may take several weeks after start- ing a therapy for them to emerge. Keeping an accurate record of every therapy you take, including when you start and stop them. Docu- menting the onset of side effects may help sort out which one is causing the problem. (For a list of herbs with known side effects, see pages 6 & 7.) TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME
  • 3. HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORMdrug interactionsSt. John’s Wort (hypericin), a popular herb used for mild supplement with anti-HIV drugs who experience seriousdepression, has possibly serious interactions with prote- stomach problems (diarrhea, nausea or vomiting) mightase inhibitors and non-nucleoside reverse transcriptase consider stopping it to see if these symptoms lessen.inhibitors (NNRTI). St. John’s Wort is processed in the A group in Pittsburgh has shown that the commonbody by the same enzyme used for processing many drugs, herb, milk thistle, also interacts with the p450 enzyme. Itincluding protease inhibitors and most NNRTIs. is may also interact with many drugs used to treat HIV.enzyme is called p450, and several diet supplements and A Canadian group has shown that vitamin A supple-herbs have reported e ects on it. Depending on how ments (beta-carotene and other retinoids) have an e ectthese products interact with p450, using anti-HIV drugs on the p450 enzyme. While this was based on test tubewith them could either raise or lower the blood levels of studies, the information suggests that there might bethe anti-HIV drugs. Herbs with reported e ects on p450 possible vitamin-drug interactions as well. It’s then easyinclude St. John’s Wort, garlic, ginseng, melatonin, milk to start wondering if food itself may interact with drugs.thistle (silymarin), geniposide and scullcap. For more ere are food-drug interactions, which is why certaindetailed information on St. John’s Wort, read page 8. drugs are absorbed better when taken with or without food. At the National Institutes of Health’s (NIH) HIV Grapefruit inhibits the p450 enzyme system andclinic, one woman who started a regimen with ritonavir in the early days of protease inhibitors some people(Norvir) and then started on garlic supplements devel- drank grapefruit juice together with the older version ofoped severe nausea and vomiting, which resolved a er saquinavir (Invirase), which was poorly absorbed by thestopping the garlic. e garlic may have increased the body, in hopes of increasing its blood levels and e ective-levels of ritonavir, and thus its side e ects. A second ness. ( e newer version, called Fortovase, has correctedcase also reported that garlic supplements may have this problem.) However, in general, drinking grapefruitenhanced the side e ects from using ritonavir. It is juice with protease inhibitors might increase their bloodunclear, however, if garlic was increasing the risks of levels to dangerously high levels and increase the risk ofritonavir-related side e ects or if it was the actual cause side e ects. 3of them. (See herbal side e ects chart on pages 6 & 7.) Not a great deal is known about food-drug interac-Subsequently, small single-dose studies of ritonavir and tions in general. Does this mean that people should stopgarlic do not suggest a serious herb-drug interaction, but eating food? Absolutely not! But the point is that wemore research is needed. don’t know how food may cause various interactions. is Garlic may also increase the risk of side e ects asso- underscores that supplementing with vitamins, in pillciated with other anti-HIV drugs. is information, forms, could carry some risks along with its unknowncoupled with knowing that garlic has an e ect on p450, bene ts. e value of good nutrition for overall health issuggests that until more is known people should use well known; the value of supplementing with vitamins iscaution when combining high doses of garlic with anti- not. is doesn’t mean that people should not use vita-HIV drugs that use p450. Moreover, people using the mins, but rather it means buyers beware! An article in The Lancet reports a number of herb-drug interactions that include the following herbs: • Betel Nut • Ginkgo • Psyllium • Xiao chai hu tang • Chili Pepper • Ginseng • St. John’s Wort • Valerian • Devil’s claw • Guar gum • Saiboku-to • Yohimbine • Dong quai • Kava • Shankhapushpi • Garlic • Papaya • Sho-saiko-to © PROJECT INFORM 1375 MISSION STREET SAN FRANCISCO, CA 94103 2621 415 558 8669 FAX 415 558 0684 SUPPORT PROJECTINFORM.ORG WWW.PROJECTINFORM.ORG
  • 4. talking with your doctor To lessen the chance of herb-drug and support their patients, in a non- to capture information about drug interactions, experts encourage people judgmental way, about using these interactions and side e ects is to to have more in-depth discussions therapies. And it may very well be record all the supplements you use about complementary therapy with the patients who actually drive this in a complete drug history. It’s also their doctors and pharmacists. is learning curve. important for patients, doctors and may take some getting used to for However, patients also need to be pharmacists to keep up to date on both patients and doctors alike. open and honest about what they’re the latest drug-herb and drug-vita- Doctors may need to learn to listen using and considering. One way min interaction studies. conclusion ere are generally two schools of thought about using whether and how to better regulate the marketing of vitamins. One is that people should take vitamin nutritional supplements and herbs. supplements in pill form. e other is that people ere is a great di culty in evaluating herbs and should simply improve their nutrition and increase herb-drug interactions because o en the active ingre- their vitamin intake through better eating. Likely the dient in the products and its dose are not known. best approach for people at risk for vitamin de cien- Although drug interaction studies for medications cies is one that lies somewhere between these two typically take a matter of a week to ten days, drug- approaches. herb interaction studies are expected to take much It’s unknown if the body can really use vitamins longer. is is a more expensive process since people that are delivered from pills. Some contend that will probably have to take herbs for a few weeks in order for the body to optimally absorb and use before an e ect is seen. vitamins they need to be delivered through better Even when the interactions are known for 4 nutrition, in foods where they exist in complex one particular product, it’s unclear how they forms which may help the body to better will relate to similar products because of the use the nutrients. lack of control over dosing. Because noHERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORM Herbal remedies and other studies have determined the proper or vitamins are sold as “food supple- best dose of many complementary ments” and do not undergo the therapies, researchers face another rigorous testing that prescription challenge in rst selecting the dose meds do. ey’re not regulated and of herbs to use in studies. Fund- may not reveal all of a product’s con- ing for these studies still remains a tents on its label. ey also may not problem and a limitation to moving contain the ingredient(s) listed or the forward rapidly. Many companies amount(s) claimed. Don’t assume that that sell complementary therapies are just because something is available over reluctant to fund studies which may the counter or is “natural” that it doesn’t reveal their products are not useful, have have side e ects or won’t interact nega - side e ects or have interactions with com- tively with your other meds. mon meds. is information could hurt In the US alone, it’s estimated that $20 billion their pro t margins. Pharmaceutical compa- was spent on complementary therapies in 2001. nies are also unwilling to fund these studies e use of these therapies has risen almost 400% in for many of the same reasons, and the FDA does not the past eight years, and it’s estimated that half the require them. people in the US use them. Currently, the industry Whatever the possible bene ts of herbs, vitamins has done very little to document the safe and e ec- and supplements, there’s simply no meaningful tive use of its products. It’s unlikely that it ever will. information to guide making decisions when using e US government, through the NIH, has esta- them. Be aware that using them entails some risk. blished two botanical centers to evaluate these types For more information on studies of herbs and vita- of therapies. A third center will be funded shortly. mins conducted in HIV disease, see pages 8–12. Every few years, new discussions are held about TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME
  • 5. HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORMbuyer beware!Some herbal remedies contain controlled and possibly taking one of the supplements. It was tested and founddangerous substances banned by the FDA. e FDA read- to contain a medication used to treat diabetes. e addi-ily admits that it doesn’t have enough enforcement to tional medication in the claimed “natural” product led toensure that these products stay o store shelves. Media an overdose for that person.exposés on this topic in California reveal countless tales To protect yourself, seek reputable sellers, investigateof people harmed by products that contain lead, arsenic, the product and seek guidance from trained professionals.anabolic steroids and other dangerous substances. Other resources that may help are ones that address fraud A few years ago a number of Chinese herb supplements issues, such as state AIDS Fraud Task Forces and Projectto manage diabetes were pulled from the shelves by the Inform’s publication, How to Identify AIDS Fraud, avail-California Food and Drug Board. is followed an inci- able at 1-800-822-7422 and www.projectinform.org.dent when a person with diabetes was hospitalized a ervitamins and potential side effects Vitamin A and beta-carotene Perhaps the most toxic vitamin. At high doses (more than 25,000 IU per day) toxicities are more likely, including loss of appetite, weight loss, bone malformations, spontane- ous fractures, internal bleeding, liver toxicities and birth defects. Vitamin B-6 (pyridoxine) Reversible neuropathy has been reported in people taking high doses (500mg to 6 grams a day) over extended periods of time. For people with previous side effects as- sociated with taking higher doses, symptoms resumed at doses as low as 50mg per day. (NOTE: The recommended daily allowance of this vitamin is 2mg per day.) Vitamin B-12 In very rare instances, allergic reactions have been reported. Folate High doses have been associated with reduced zinc absorption and have been shown 5 to mask signs of vitamin B-12 deficiencies. Vitamin C High doses can cause diarrhea and gastrointestinal distress. Buffered formulas are available and may decrease stomach problems. People with a history of kidney stones should consult a doctor before taking high doses. Vitamin D Potentially very toxic, can cause bone lesions. Toxicities reported with a single high dose supplement. Thiamin Very high intravenous doses have caused intoxication, headache, convulsions, muscu- lar weakness, paralysis and cardiac arrhythmias. Biotin No reported toxicities. Vitamin E At doses higher than 1,000mg (1,500 IU) it can interfere with blood clotting. Prolonged use of high doses (800–3,200mg/daily) has been associated with nausea, diarrhea, muscle weakness and fatigue. Riboflavin No reported toxicities. Pantothenic Acid No reported toxicities in humans. Vitamin K No reported toxicities at doses of up to 500 times the required daily allowance (0.5mg/kg/day). Niacin Toxicities may be related to formulation. Nicotinic acid can cause itching, nausea, diarrhea and vomiting at doses of 2 to 4 grams/day. Nicotinamide only rarely produces these toxicities. At high doses, less common but more serious side effects may include liver injury, muscle disease, vision problems, low blood pressure, heart disease and poor blood clotting. © PROJECT INFORM 1375 MISSION STREET SAN FRANCISCO, CA 94103 2621 415 558 8669 FAX 415 558 0684 SUPPORT PROJECTINFORM.ORG WWW.PROJECTINFORM.ORG
  • 6. herbal side Virtually any herb has the potential of causing side effects. For some, the Compound Q (Trichosanthes, Guaiougen, risks are small and only occur when herbs are used in large quantities or for GLQ223, Chinese cucumber root) long periods of time. For others, severe and life-threatening side effects have Severe neurologic side e ects (ranging been seen even at very low doses with a single use. A good herbal practitioner from dizziness to coma) at very high doses, low blood sugar, induces abortion. B should discuss the potential risks of both side effects and herb-drug interac- tions with you. However, this shouldn’t replace discussing these interactions Dandelion (Taraxacum) and side effects with your doctor and pharmacist. Excessive gas, nausea and vomiting; skin The following is a list of herbs and their known side effects. Those with FDA rashes, allergic reaction; increased urin- ation (diuretic). Diuretic e ect is likely no warnings or heightened safety concerns are highlighted in grey. This list is not more than what is seen with co ee. BC comprehensive. If you don’t see the herb(s) you may be taking on this list, it does not mean that there are no reported or possible side effects from using them. Many Devil’s Claw Root resources exist on the internet and elsewhere providing even more comprehensive (Hapagophytum procumbens) Induces abortion. C information. One is www.personalhealthzone.com/herbsafety.html. Dock Roots Increased bowel movements, diarrhea. C Akebia trifoliata caulis (Mu Tong) creased urine (diuretic), low blood sugar Echinacea Kidney toxicity, kidney failure. is herb and may impact estrogen activity. BC Skin rash and insomnia. Allergic reaction. contains aristolochic acid. In 2001 the May aggravate auto-immune disorders FDA classi ed it as a Class 1 toxic sub- Calamus Kidney toxicity. (like lupus). AB stance and product recalls were started. Cassava beans Ephedra Aloe Vera (Carrisyn) Heart failure, stroke, increased blood Severe diarrhea without proper prepar- May cause cyanide poisoning and death if consumed in large quantities. C pressure. ation, must be processed properly. Refrain from ingesting aloe vera plant directly, or Chamomile Ganoderma (Ling-zhi, reishi) use proper preparations. AB Belongs to ragweed family. People with Can inhibit blood clotting and trigger allergies to ragweeds may experience al- hemorrhagic syndrome. AB Apple seeds May cause cyanide poisoning and death if lergic symptoms to chamomile. A Garlic (Allium sativum, Dasuan) consumed in large quantities. C Chaparrel (Larrea divericata, Larrea Can inhibit blood clotting and interfere tidentata, Creosote bush) with thyroid function. Diarrhea, vomiting, 6 Apricot Seeds nausea, weight loss, loss of appetite and May cause cyanide poisoning (possibly Nausea, vomiting, diarrhea, cramps, skin irritation, mouth sores and may promote skin rashes have been reported. AB death) if consumed in large quantities. CHERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORM tumor growth. e FDA issued a health Germander Asarum sieboldii herba cum Radix (Xi Xin) warning in 1992 and many companies’ Inflammation of the liver (hepatitis), Kidney toxicity, kidney failure. is herb voluntary removed chaparrel from their liver injury and death. Early symptoms contains aristolochic acid. In 2001 the products or recalled products containing appear to resolve a er stopping the herb. FDA classi ed it as a Class 1 toxic sub- chaparrel. Some may still exist on the Re-starting herb appears to result in im- stance and product recalls were started. market, however. B mediate return of the problem. e risk Astragalus (Huang-chi) Cherry pits or degree of liver injury is not appar- Low blood pressure, low blood sugar and May cause cyanide poisoning and death if ently associated with dose or duration increased urine production. May result in consumed in large quantities. C of use. E dizziness and fatigue. AB Ginseng (Wuchaseng, Siberian, Choke cherry pits Atractylodes (Bai-zhu, Pai-chu) May cause cyanide poisoning and death if wjuia, ren-shen) Liver toxicity, sedation, dehydration (di- consumed in large quantities. C Ginseng is touted the “most abused” uretic), low blood sugar. AB or “mis-used” herb. Ginseng Abuse Coconoosis Syndrome (GAS) is associated with its Bitter almond seeds (Codonopsis pilosula, Tang-shen) long-term use. Various forms exist. Panax May cause cyanide poisoning (possibly Low blood pressure. B and Eleutherococcus ginsengs produce death) if consumed in very large quan- morning diarrhea, insomnia, nervous- tities. C Coltsfoot ness, depression, confusion, skin rashes Liver toxicity, light sensitivity. and high blood pressure. Ginsengs are Black Tree Fungus Comfrey [Symphytum officionale known to increase e ects of some anti- Can inhibit blood clotting and trigger (common comfrey), S. asperum (prickley depressants called Monoamine Oxidase hemorrhagic syndrome. A comfrey), and S. x uplandicum (Russian Inhibitors (MOIs). Women may experi- Borage comfrey)] ence breast swelling or tenderness and Liver toxicity. Liver toxicity: Vaso-occlusive disease, changes in menstrual cycle (amenorrhea) fatal liver intoxi cation. In 2001 the FDA’s due to impact on estrogen. ABCD Buckthorn Bark (Rhamnus) Center for Food Safety and Applied Nu- Increased bowel movements, diarrhea. C trition sent letters to dietary supplement Horsetail (Equisetum arvense) Excitement, loss of appetite and muscle Burdock (Arctium lappa) manufacturers advising that comfrey control, diarrhea, labored breath, con- Neurologic e ects, blurred vision, dry be removed from all nutritional health vulsion, coma and death. C mouth, constipation, bizarre behavior and products due to potentially serious and speech (including hallucinations), in- life-threatening consequences of comfrey ingestion. BE TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME
  • 7. effects chart HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORMHypericin (St. John’s Wort) Very high doses can cause altered mental Causes cancer and liver toxicity in animalMay induce sensitivity to light (photosen- status, liver damage and death. Fairly studies. Csitivity), resulting in severe rash following small amounts can cause headaches,sun exposure. May also have interactions cramps and nausea. C Schizandra (Gomishi)with some anti-depressants called Mono- Depression, low blood pressure, contrac-amine Oxidase Inhibitors (MOIs). In Pau d’Arco tions of the uterus. B2000, the FDA issued a warning about Nausea, vomiting, weight loss and has been shown to inhibit blood clotting. AB Senna leaves (Cassia angustafolia)this herb and its interactions with anti- Increased bowel movements, diarrhea. CHIV drugs. ABC Peach pits May cause cyanide poisoning (possibly Shave GrassIsatis (Pan-lan-ken, dyers’ wood root) Excitement, loss of appetite and muscleCan inhibit blood clotting. B death) if consumed in large quantities. C control, diarrhea, labored breath, con-Iscador (Mistletoe) Pear seeds vulsion, coma and death. Shave grassLiver toxicity, seizures, shock, heart May cause cyanide poisoning (possibly may lead to thiamine deficiency withfailure. BC death) if consumed in large quantities. C symptoms. CJuniper Berry Pennyroyal Oil (Hedeoma pulegiodes, Shiitake MushroomStomach upset. C Mentha pulegium) (Lentinus edodes, Xiangling) Has been used to induce menstruation Can inhibit blood clotting and triggerKava (Piper methysticum) and induces abortion. Has caused death hemorrhagic syndrome. Skin rashes, lowLiver-related injuries including hepati- due to kidney and liver toxicity. C blood pressure. ABtis, cirrhosis and liver failure. In at leasteight cases liver failure resulting in liver Peony (Paeonia, Moutan bark, chi-shao, Stephaniatransplantation was required and death bai-shoa, mudan-pi) Adverse e ects were published in Febru-has been reported in three. In 2002 the Stomach upset, nausea, diarrhea, depres- ary 1993, of 48 women identi ed withFDA issued a warning noting that while sion, low blood pressure, increased urina- serious kidney disease associated withliver-related injury associated with kava tion (diuretic). B the use of a Chinese diet herbal productuse is low, consumers should be warned containing this herb. Eighteen had termi- Plum pits nal kidney failure that will require eitherof risks. Further, those with liver disease May cause cyanide poisoning (possiblyor taking other drugs that a ect the liver kidney transplantation or life-long renal death) if consumed in very large quan- dialysis. Eshould be especially careful. tities. CKelp (Laminara japonica, Kombu) Sweet wormwood Poke Plant (pokeweed, inkberry) (Artemisa, Quindhaosu, mugwort)Interferes with thyroid function. Goiters. B e root is particularly toxic. Can cause 7 Allergic reactions, skin rashes, alteredLicorice severe stomach upset, shortness of breath mental status. BHigh blood pressure, water retention and and death. Children have died from eatingeven serious heart problems. ABC the berries. C Tang-kuei (Angelica, Du-huo, bai-zhi) Interferes with blood clotting and plate-Life root Privet (Ligustrum, Nuzhenzi) lets, depression, sensitivity to light. BVeno-occlusive disease. Kidney failure, low blood pressure. B Tremella (Auriculariaceae,Lobelia (Lobelia inflata) Propolis Bai-mur, white tree ear)Depending on the dose, lobeline can Alleric reaction, skin rashes. B Inhibits platelets. Bcause either autonomic nervous system Prunella (Xia-ku-cao, woundwort, allheal)stimulation or depression. At low doses, it Yarrow (Achillea millefoleum, Milfoil) Low blood pressure, increased urination Interferes with blood clotting, allergic reac-produces bronchial dilation and increased (diuretic), contractions of uterus, in-respiratory rate. Higher doses result in tions, skin rashes, sensitivity to light. BC creased bowel movements. Brespiratory depression, as well as sweat- Yohimbe (Pausinystalia yohimbe)ing, rapid heart rate, hypotension, and Red Clover Kidney failure, seizures and death. Shouldeven coma and death. As little as 50mg of Interferes with blood clotting. B also be avoided by individuals with lowdried herb or a single milliliter of lobelia Rehmennia (Sheng-ti-huang) blood pressure, diabetes, and heart, liver ortincture has caused these reactions. E Low blood sugar. B kidney disease. Symptoms of over dosageLycium Fruit (Kuo-chi-tzu, include weakness and nervous stimulation Salvia (Tan-shen) followed by paralysis, fatigue, stomachgouqizi, wolfberry, false jessamine) Interferes with blood clotting, platelets,Low blood sugar, mouth sores. B disorders and ultimately death. Certain tiredness/fatigue, low blood pressure, foods (cheese, red wine, liver) can increaseMagnolia low blood sugar, increased urination likelihood of side e ects, as can concurrentAdverse e ects were published in Febru- (diuretic). B use of over-the-counter therapies (dietary 1993, of 48 women identi ed with Sassafras Root Bark aids, decongestants). Eserious kidney disease associated with theuse of a Chinese diet herbal product con-taining this herb. Eighteen had terminalkidney failure that will require either SOURCES: A: Stephan Korsia. IHITTG, September 1992. (IHITTG was a publication of AIDSkidney transplantation or life-long renal Project Los Angeles dedicated to alternative and complementary therapy.) B: Kassier, W.J., et.dialysis. E al., Arch Intern Med-Vol. 151, November 1991. C: The Medical Letter, Vol. 21, No. 7 (Issue 528), April 1976. D: Siegel, R., JAMA, Vol. 24, No. 15, April 1979. E: FDA Document, IllnessesNutmeg and Injuries Associated with the Use of Selected Dietary Supplements, May 2000. © PROJECT INFORM 1375 MISSION STREET SAN FRANCISCO, CA 94103 2621 415 558 8669 FAX 415 558 0684 SUPPORT PROJECTINFORM.ORG WWW.PROJECTINFORM.ORG
  • 8. NIH study cautions use of St. John’s Wort with anti-HIV drugs A study conducted by the NIH St. John’s Wort (Hypericum perfo- One possible limitation of the found a signi cant interaction ratum), and the protease inhibitor, nding is that it is not clear how it between the popular herbal therapy, indinavir (Crixivan). Indinavir applies to the various forms of St. blood levels were greatly decreased John’s Wort on the market. ere when the two were used together, is no way of knowing its quality or greatly reducing indinavir’s anti- how much St. John’s Wort is actu- HIV activity. is can quickly lead ally present in the products. Di er- to developing resistance to indina- ent brands may have a stronger or vir. People commonly use St. John’s weaker e ect. Also, the methodol- Wort as a mild anti-depressant. ogy of the study has not been fully St. John’s Wort is also likely to described yet. have the same e ect on other protease As this study shows, it’s very inhibitors as well as NNRTIs. People possible for some herbal and nutri- who take these drugs are advised tional supplements to lower the not to use St. John’s Wort. Similar e ectiveness of anti-HIV drugs or problems with drug interactions may other medications. People who use occur between the herb and drugs complementary therapies should used to treat other life-threatening ill- always discuss possible interactions nesses, such as heart disease. with their doctors and pharmacists. 8 vitamin A (beta-carotene and retinoids)HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORM and anti-HIV drug interactions In general, when used at reasonable doses on their own, fold less beta-carotene than advertised, and most were at nutritional products like vitamin A supplements are least half as much than stated. considered safe. New information suggests that when All forms of vitamin A (retinal, retinol, retinate and used with other therapies, including anti-HIV drugs and beta-carotene) as well as all the products tested had other nutritional products, interactions may occur that moderate (45–65%) to strong (65–100%) inhibitory alter a product’s e ectiveness and safety. e ect on the p450 enzyme. erefore, these products (and De ciencies in vitamin A (retinol, beta-carotene) have possible other nutritional health products) are very likely been associated with advanced HIV disease. It remains to interact with anti-HIV drugs. However, human stud- unclear if taking vitamin A supplements such as reti- ies are needed to understand the extent of these ndings. noids or beta-carotene helps people with HIV beyond ese data suggest that there are possible, real vita- correcting the de ciency. Moreover, questions remain as min-drug interactions with potentially harmful results to whether or not vitamin A supplements cause vitamin- for people taking anti-HIV drugs. Much more informa- drug interactions. tion is needed to fully understand the scope of these A team in Canada set out to evaluate whether or not interactions and their impact on the e ectiveness and di erent vitamin A supplements interact with the p450 side e ects of therapies. is information would also enzyme. e team evaluated four tablets and two so gel be needed on how to modify doses of either therapy capsules. All of the tested products had lower beta-carotene to reduce the risk of developing drug resistance and content than stated on their labels. One product had ten- increase the chances of bene ting from both. TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME
  • 9. HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORMselenium and hivControversy remains over using selenium in people withHIV. Selenium is a toxic substance that gets spread into theenvironment through the burning of fossil fuel and otherindustrial processes. Trace amounts of it is often found indrinking water. Symptoms from consuming too much sele-nium include brittleness and loss of hair and nails, skin redness,blisters, vomiting, fatigue, neurological defects and damage to the liverand spleen.Trace amounts of selenium are in the foods we eat. low selenium levels have higher rates of HIV in vag-At these low levels, selenium is essential for proper inal secretions. Again, it remains unclear if seleniumimmune function. e US Recommended Daily de ciency is a cause or an e ect of HIV disease pro-Allowance of selenium (all ages and genders) is 55 gression and if supplements will help or hurt.micrograms (mcg). Levels are slightly higher for A study conducted at the University of Miamipregnant (60mcg) and lactating (70mcg) women. compared selenium supplements (200µg/day) to e Institute of Medicine has proposed that the placebo in 259 people living with HIV (147 men,maximum daily intake before causing toxic e ects is 112 women). Information about CD4+ cell count,roughly 400mcg for adults. viral load and other parameters were collected at the Selenium de ciencies are rarely seen in the US, rst study visit and then every six months therea erthough they have been seen among people on Total for two years.Parental Nutrition (TPN), or intravenous nutrition. One component of the study was to evaluate theTPN is sometimes used to treat wasting syndrome frequency of hospitalizations among those receiv-in people with HIV. It is standard practice for doc- ing selenium compared to placebo. Unfortunately, 9tors to check selenium levels in people on TPN and sloppy data reporting leaves results of this aspect ofsupplement as necessary. the study completely uninterpretable currently. Selenium toxicity has been seen in people using Additionally, researchers examined blood lev-selenium supplements. In one case, high levels led to els of selenium in 112 HIV-positive women onselenium poisoning in a man using supplements as anti-HIV therapy. ey looked for links betweena way to manage his fatigue. Investigators analyzed selenium levels and the risk for pre-cancerous cervi-the over-the-counter product and found selenium cal cells (cervical dysplasia). While selenium levelslevels of 500–1,000 times the amount labeled for were lower in women who developed dysplasia,each pill. is led to warnings noting that unusual using supplements made no di erence in the risk ofdiets and vitamin supplements are the most com- developing dysplasia. Five women who used sele-mon causes of selenium toxicity in the US. nium supplements and seven on placebo developed Several studies suggest that low levels of selenium dysplasia.are related to HIV disease progression. One study In short, the most that can be concluded from theseof 24 children and another of 125 adults has shown reports is that it remains entirely unknown if seleniumthat those with these de ciencies were at a greater supplements o er any bene t or harm, whatsoever.risk for disease progression and death. However, Risks for cervical dysplasia appear slightly higher whenit’s unknown whether or not selenium supplements selenium levels are lower, but selenium supplementswould make a di erence. do not appear to eliminate this risk. is sloppy data Other studies suggest that HIV needs selenium in reporting is a tragedy. Well-designed research is criti-order to reproduce. Some have proposed that when cal to evaluating the possible bene ts (and risks) ofHIV uses all the selenium in a given cell, it may selenium supplements.leave that cell to nd more selenium by infectingother cells. Interestingly, HIV-positive women with© PROJECT INFORM 1375 MISSION STREET SAN FRANCISCO, CA 94103 2621 415 558 8669 FAX 415 558 0684 SUPPORT PROJECTINFORM.ORG WWW.PROJECTINFORM.ORG
  • 10. amounts of selenium vitamin E, vitamin A and in various foods: anti-HIV therapies Previous reports suggest that vitamin E levels Micro- % Daily are decreased in people living with HIV. Also, Food grams Value low levels of vitamin E have been associated Brazil nuts, dried, unblanched, 1 oz 840 1,200 with increased risk of disease progression. Tuna, canned in oil, drained, 3.5 oz 78 111 Researchers in the United Kingdom sought Beef / calf liver, 3 oz 48 69 to evaluate vitamin E levels among 33 people before and six weeks a er starting anti-HIV Cod, cooked, dry heat, 3 oz 40 57 therapy. ey compared levels to those seen in Noodles, enriched, boiled, 1 c 35 50 otherwise healthy HIV-negative people. ose Macaroni & cheese (box mix), 1 c 32 46 taking multivitamins were not eligible. Turkey, breast, oven roasted, 3.5 oz 31 44 Investigators found that before starting anti- Macaroni, elbow, enriched, HIV therapy, vitamin E levels were lower (21 boiled, 1 c 30 43 µmol/l) among people with HIV compared to Spaghetti w/ meat sauce, 1 c 25 36 HIV-negative people (30 µmol/l). Contrary to ear- Chicken, meat only, 1/2 breast 24 34 lier reports, people with AIDS had slightly higher Beef chuck roast, lean only, vitamin E levels (24 µmol/l) than people with oven roasted, 3 oz 23 33 HIV who did not have AIDS (19 µmol/l). A er Bread, enriched, whole wheat, six weeks of therapy, vitamin E levels normalized 2 slices 20 29 among people with HIV (28 µmol/l) compared to Oatmeal, 1 c cooked 16 23 the HIV-negative people (26 µmol/l). Egg, raw, whole, 1 large 15 21 Vitamin A levels were also evaluated. No 10 Bread, enriched, white, 2 slices 14 20 di erences were seen in vitamin A levels either before or six weeks a er starting anti-HIV ther- Rice, enriched, long grain,HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORM apy. Moreover, vitamin A levels were in normal cooked, 1 c 14 20 healthy ranges, roughly equivalent to those seen Cottage cheese, low-fat 2%, 1/2 c 11 16 in HIV-negative people, both before and a er Walnuts, black, dried, 1 oz 5 7 therapy. Further, no di erences were seen in Cheddar cheese, 1 oz 4 6 vitamin A levels between healthy HIV-positive people and those with AIDS. is study suggests that for people tak- ing anti-HIV therapy, vitamin E supplements are likely not necessary. Moreover, vitamin A de ciencies were not noted with HIV infec- tion, regardless of stage of disease. It remains unknown if vitamin E supplements will bene t people not on anti-HIV therapy. www.projectinform.org i Go online around the clock and get connected to treatment information in the privacy of your own home! TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME
  • 11. HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORMvitamin supplements and HIV in women(implications for everyone)Vitamin deficiencies have been seen in people even at early stages of HIV infection. This has led to aninterest in using multivitamins, particularly in resource poor settings and those where malnutrition isa problem. A study in Tanzania, Africa among HIV-positive pregnant women showed that using multi-vitamins led to fewer deaths of unborn children, increased birth weights and fewer pre-term births.However, trends were noted that children born to HIV in breast milk, higher rates of mother-to-HIV-positive mothers who took multivitamins dur- child HIV transmission, lower CD4+ cell countsing pregnancy were more likely to be infected with and more rapid disease progression. Four hundredHIV. Because of this, another study was started in women took either placebo or vitamin A at the doseKenya to examine the impact of using daily multivi- recommended by the World Health Organizationtamins (or placebo) and evaluate its impact on vagi- for correcting symptomatic vitamin A de ciencies innal and cervical presence of HIV. women of child-bearing potential. e study found e use of multivitamins was associated with that the supplements had no e ect whatsoever onslightly higher CD4+ and CD8+ cell counts and no vaginal presence of HIV, blood levels of HIV, oroverall changes in HIV levels in the blood. However, CD4+ or CD8+ cell counts.it was also associated with increased vaginal presence ese ndings held true even among the 59% ofof HIV, with about 1/2 log higher levels of HIV in women with notable vitamin A de ciencies at thevaginal swabs. e percentage of vaginal cells with start of the study. ey suggest that while vitaminHIV was higher among those taking daily multi- A de ciencies may be associated with poorer out-vitamins (31%) than those on placebo (17%). e comes in passing HIV from mother to child and of 11di erences were less striking in cervical cells. HIV disease in general, supplements are unlikely to Researchers speculate that using daily multivita- address these problems. As with the other study, thismins among women is unlikely to protect them study did not evaluate using supplements togetherfrom HIV disease progression and may increase the with anti-HIV therapy.chances of passing HIV onto others. e results areperhaps more relevant to places where anti-HIVtherapies are not available or to those who choosenot to use them together with multivitamins. e useof multivitamins was linked to improved markers ofimmune health (slight increases in both CD4+ andCD8+ cell counts). It remains unknown whether theincreased vaginal presence of HIV from using mul-tivitamins would be controlled while using anti-HIVtherapy. ( e women in this study were not on anti-HIV therapy.) Another Kenyan study found that vitamin Ade ciencies in blood were associated with increasedvaginal presence of HIV during pregnancy, increased TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME
  • 12. zinc deficiencies and HIV De ciencies in dietary zinc have been associated with gests that, in general, improving a person’s diet results in decreased immune function and possibly increased HIV more normalized zinc levels. reproduction. Drug users are at particular risk for zinc e study also showed that people with lower zinc levels de ciencies for a number of reasons. ese include poor had somewhat lower CD4+ cell counts and were more diets, poor absorption of nutri- likely to have counts below 200. It would be rash to sug- ents and poor processing of gest, however, that low zinc levels are the cause of lower nutrients by the body. CD4+ cell counts and not merely an e ect of disease  A team in Florida examined progression. In general this study is encouraging in that the nutritional and immuno- it shows that simply improving diet, without supple- For more treatment logic status of 118 HIV-posi- ments, leads to increased zinc levels in the blood and information, call tive injection drug users. ey better immune status. Another study is ongoing to see Project Inform’s found that people whose diets if zinc supplements will result in improved blood levels toll-free National included foods with higher lev- of zinc and to see if it has any e ect on HIV or immune HIV/AIDS els of zinc showed higher levels markers. Treatment of zinc in their blood. is sug- Hotline at 1-800-822-7422. 12HERBS, SUPPLEMENTS AND HIV . JANUARY 2005 . PROJECT INFORM Yes, I want to help Project Inform remain at the forefront of HIV treatment information! PARTNERS IN HOPE  Enclosed is my donation of:  $35  $50  $100  $250  $500  $1,000  $2,500  Other $_______  Enclosed is my donation of: $_____ per month for _____ months.  (circle one) In Honor of / In Memory of: _________________________________________________________  Please send me information on making a bequest or planned gi . ADDRESS PAYMENT Circle One: CHECK AMEX MC VISA DISCOVER Dr./Mr. / Ms. / Mrs.  This is a new address. Credit Card # Exp. Date Address City State Zip Print Name Shown on Card Day Phone Email Phone Signature FACT TOLL FREE NATIONAL HIV/AIDS TREATMENT HOTLINE 1 800 822 7422 LOCAL AND INTERNATIONAL 415 558 9051 MONDAY FRIDAY 10 4 PACIFIC TIME