Upper abdominal pain, nausea, and vomiting

Nausea, vomiting, and disturbed digestion are frequently occurring side effects of antiretrovirals.

Treatment of upper abdominal pain
Pain in the upper abdomen, or dyspepsia, is often characterised by a burning feeling in the throat, oesophagus, or stomach.
Firstly, one should try to eat something at the time of taking the medication, unless intake on an empty stomach is specifically required. It often also helps to modify eating or living habits. It is advisable not to eat excessively and to avoid too much fat, to reduce alcohol intake and to quit smoking.
If these measures do not help sufficiently, medication may be necessary. In case of light symptoms, the first option would be an antacid substance, such as an algeldrate with magnesium trisilicate. Extended usage of high dosages can also result in side effects and is therefore discouraged. Delavirdine, indinavir, nelfinavir and zalcitabine should be taken two hours prior to the ingestion of an antacid. [Burger-DM et al.] If an intermittent, sharp pain is felt in the upper abdomen, particularly at night, which does not diminish after eating, usage of an H2-antagonist such as ranitidine or cimetidine may be indicated. These substances result in a reduced stomach acid production. Side effects are rare and consist mainly of headache and dizziness. Interactions between these medications and atazanavir have not yet been investigated. For this reason, if these medications are used in combination with atazanavir, caution should be observed. [EMEA]
In situations involving regurgitation attacks bringing stomach and intestinal contents back toward the oesophagus (reflux-oesophagitis), the so-called "proton-pump inhibitors", such as omeprazol, lansoprazol, pantoprazol or rabeprazol, are indicated. The most prevalent side effects of these medications are, again, gastrointestinal disorders and headache. A proton-pump inhibitor should not be used simultaneously with delavirdine, atazanavir or indinavir.

Treatment of nausea and vomiting
[Farmacotherapeutisch Kompas] [Bartlett-JG, 1998] [Merigan Jr-TC]
The primary medicinal treatment for nausea and vomiting is domperidon, available as tablet or suppository. It has the advantageous property of not being able to penetrate the brain, thereby preventing side effects upon the central nervous system, which are possible with some other treatments. The efficacy of domperidon is based on the stomach being more quickly emptied than normal. The stomach contents move more quickly into the intestine, thereby reducing the complaints. Ten mg domperidon 3-4 times daily can be taken before eating and going to sleep. When necessary, the dosage can be increased to 20 mg 3-4 times daily. Side effects are rare; only in a few cases intestinal cramps have been reported.
In addition, metoclopramide can be used against nausea and vomiting; this has a similar effect. Metoclopramide can, however, pass into the brain, leading to side effects especially when used in high dosages. These include sleeplessness, fatigue, and mobility impairment. Constipation and diarrhoea can also occur. The oral dosage of metoclopramide is 5-10 mg 3-4 times daily.
Cisapride is not recommended due to the risk of its interaction with various medications, namely (fos)amprenavir, delavirdine, efavirenz, indinavir, nelfinavir, ritonavir and saquinavir.
Cyclizine or meclozine may on the other hand be used. They exhibit few side effects but their efficacy is often moderate.
If these medicines provide insufficient help, acute situations may call for the use of ondansetron, 12 mg twice daily. This is normally used only in case of nausea or vomiting as a result of medications or radiation in the treatment of cancer. Side effects may include headache, dizziness, slight drowsiness, diarrhoea or constipation.
Haloperidol is normally used against hallucinations and, in low dosages, is also effective against vomiting. It is one of the medicines of last resort and may not be used in combination with ritonavir.

Alternative therapy
Ginger is derived from the ginger plant (Zingiberis officinalis). [Micromedex] Documented research regarding the use of ginger by HIV-positive individuals is lacking. Some research, however, does compare the use of ginger, usually in a dosage of 500 mg to 1 gram per day, to other medications that are used to combat nausea and vomiting. The research provides some indications that ginger is effective, but the studies are either small or have methodological flaws. [Pace-JC] [Meyer-K] [Schmid-R] [Mowrey-DB] [Phillips-S] [Bone-ME] In haemophiliac patients, caution is advised regarding the simultaneous use of protease inhibitors because they have been associated with longer than normal bleeding bouts. Ginger could increase this effect.
A number of controlled studies on the use of medicinal cannabis (as well as dronabinol) to combat nausea and to improve the appetite in HIV-infected individuals has been published. [CFH] In one randomised study involving 139 AIDS patients with anorexia and weight loss the efficacy of 2.5 mg dronabinol twice daily was investigated. [Beal] Compared to the placebo group, patients experienced an increase in appetite and a decrease in nausea. Another randomised, placebo-controlled study showed that 5 mg dronabinol twice daily led to an increase in the percentage of body fat. [Struwe] A study involving 139 HIV-infected people suffering from the HIV wasting syndrome showed that 2.5 mg of dronabinol twice daily compared to a placebo led to improvements in appetite, mood and weight. This effect can probably be explained by the fact that dronabinol slows the emptying of the stomach. [McCallum] It may therefore be concluded that there are strong indications to suggest that dronabinol improves the appetite in HIV-infected people and causes an increase in their body weight and a decrease in nausea.
Medicinal cannabis is available on prescription as a medicine against nausea, vomiting and neuropathy. Some insurance companies will compensate the costs, but not all. Medicinal cannabis does not need to be smoked; it may also be inhaled with the use of an evaporator or it can be used to make tea. [BMC]
Various controlled clinical studies have been published regarding the effect of acupuncture. These studies indicate that positive results against nausea and vomiting can be obtained after an operation, during chemotherapy, and during pregnancy. [Vickers-AJ] However, none of these studies was performed in HIV-positive individuals, so it is not possible to draw conclusions about the possible efficacy of acupuncture against nausea and vomiting resulting from HIV medications.

Recommendations with regard to taking medicine after vomiting
[NVAB, 2000]
If the medicine is to be taken on an empty stomach (e.g. didanosine, indinavir):Within one hour after ingestion: take medicine again;
More than one hour after ingestion: do not take anything again;
If portion of medication is present in vomit: always take medicine again.
If the medicine is to be taken with food:Within 3 hours after intake: take medicine again. More than 3 hours after intake: do not take anything again. If some of the medication is present in vomit: always take medicine again.

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