Old Dog, New Trick

When it comes to diarrhea, oral rehydration is a neglected but effective therapy
by Mariel Selbovitz, MPH


Diarrhea is one of the most annoying and most common effects of HIV infection, resulting from the damage the virus causes to the gut mucosa, many of the antiretroviral drugs used to treat HIV, and opportunistic infections. Additionally, it can even be a life-threatening problem if not addressed correctly and rapidly.
Diarrhea is an exceedingly common problem in people living with HIV and the severity ranges from mild, self-limiting diarrhea to debilitating disease that can result in dehydration, malnutrition, weight loss and shock. In the U.S. it is treated with over-the-counter medications, mainly Imodium, Kaopectate, Lomotil and Pepto Bismol, and nutritional supplements, primarily L-glutamine and calcium carbonate. This past December, Napo Pharmaceuticals filed a new drug application for its first-in-class drug for HIV/AIDS-related diarrhea, crofelemer.

Diarrhea can cause you to become dehydrated through the significant loss of water and electrolytes. Symptoms include thirst, anxiety, weakness, confusion, lightheadedness, fainting, dry and pale skin, increased heart rate, and decreased blood pressure. It is best to try to prevent dehydration caused by diarrhea and treat it as effectively and quickly as possible.

Drinking enough fluids is very important when you are HIV-positive. Fluids help prevent dehydration, especially when you are taking many medications and/or experiencing diarrhea. You need a great deal of fluids to flush out medication that has been used by your body. Avoid drinking beverages that contain caffeine or alcohol, particularly if you are experiencing diarrhea, as these products cause further fluid loss. Also avoid drinking beverages that contain high amounts of sugar, especially fructose and lactose (milk), as they can exacerbate diarrhea. Oral rehydration solutions replace both the water and electrolytes lost.

Introduced in 1978, oral rehydration therapy (ORT) remains the cornerstone of management of diarrhea and subsequent dehydration globally. Oral rehydration solutions (ORS) provide a simple, inexpensive, highly effective approach to hydrating HIV patients with acute and persistent diarrhea.

Most ORS do not stop the diarrhea itself; they only treat the resulting dehydration. One formula that both replaces lost fluids and electrolytes and reduces the volume and duration of diarrhea is CeraLyte, a rice-based ORS. Data from peer-reviewed publications have shown rice-based oral rehydration solutions to be effective in reducing and stopping diarrhea and treating dehydration. Rice powder has been shown to effectively replace glucose in standard ORS and decrease stool output, duration of diarrhea, and requirement for IV fluids. Rice syrup solids have been shown to promote greater absorption and retention of fluids and electrolytes than glucose-based ORS. As a rice-based solution, CeraLyte is more effective at replenishing electrolytes than glucose-based solutions, including Gatorade, juices and sodas, or water.

The last edition of Health Care and HIV: Nutritional Guide for Providers and Clinicians, published by HRSA in 2002, recommends CeraLyte to address diarrhea and dehydration. The WHO/UNICEF ORS Recommendations list CeraLyte 70 and CeraLyte 90. A study comparing the safety and efficacy of the WHO glucose-based ORS to CeraLyte in patients with cholera, which causes severe diarrhea, found that CeraLyte was more effective.

The use of ORS in North America has been reported in a limited number of publications and primarily for the treatment of acute diarrhea in children. ORT is not just a solution for low-resource settings, but rather an equal, perhaps even superior, means of treating and preventing acute and chronic diarrhea for people living with HIV in the modern medical facilities of the U.S., Canada, and Western Europe.

ORS has been hailed as one of the most important advances of the twentieth century. Yet this intervention has not been integrated into clinical practice in the U.S. Cost estimates of not using ORS for diarrhea in the U.S. indicate that our neglect of this inexpensive, simple, effective therapy is an expensive oversight.

Ms. Selbovitz is the AIDS Treatment Education and Policy Advocacy Program Director at Health People in the Bronx, New York, and chair of the Cornell ACTG CAB. She is a member of the AIDS Treatment Activists Coalition (ATAC) and the Campaign to End AIDS (C2EA). Ms. Selbovitz holds a Master’s in Public Health from Johns Hopkins University.

March 2012