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HIV-associated peripheral neuropathy (PN)

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Related Terms
  • Anticonvulsants, antidepressants, antiretroviral therapy, antiretrovirals, ART, cobalamin, fusion inhibitor, HAART, highly active antiretroviral therapy, HIV, human immunodeficiency virus, narcotic pain relievers, narcotics, nerve, nerve cell, nerve damage, nerve pain, nervous system, neuron, neuropathy, nerves, pain, peripheral neuropathy, peripheral nervous system, PN, protease inhibitors, reverse transcriptase inhibitors, vitamin B12 deficiency.

Background
  • Peripheral neuropathy (PN) is a nervous system disorder that causes numbness, tingling, or burning, especially in the hands and feet. Peripheral neuropathy occurs when there is damage to the nerves in the peripheral nervous system. The peripheral nervous system contains nerves in the body that are outside of the brain and spinal cord. Many of these nerves are involved with sensations of external stimuli, such as pain and temperature.
  • Researchers estimate that up to one-third of HIV patients experience symptoms of PN, such as tingling and numbness in the hands and feet, burning or shooting pains throughout the body, or general aching.
  • Certain drugs, including some antiretroviral drugs (used to treat HIV), as well as high alcohol consumption, may cause peripheral neuropathy. However, the exact mechanism of action remains unknown. In cases of drug-induced peripheral neuropathy, it is recommended that patients discontinue the drug, if possible. The patient will fully recover in about eight weeks. Patients who continue to take the drugs may suffer from permanent nerve damage.
  • HIV-associated peripheral neuropathy may also be the result of HIV itself or vitamin B12 deficiency. In such cases, treatment focuses on the underlying cause. These patients typically receive highly active antiretroviral therapy (HAART) and/or vitamin B12 supplementation.
  • Drug treatments have not been approved to repair nerve damage in PN patients. However, several medications, including topical (applied to the skin) anesthetics, antidepressants, anticonvulsants (anti-seizure drugs), and narcotic pain relievers, are available to relieve symptoms.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. AIDS Map. . Accessed May 14, 2009.
  2. AIDS.org. . Accessed May 14, 2009.
  3. Burkes RL, Cohen H, Krailo M, et al. Low serum cobalamin levels occur frequently in the acquired immune deficiency syndrome and related disorders. Eur J Haematol. 1987 Feb;38(2):141-7.
  4. Johns Hopkins University HIV Guide. . Accessed May 14, 2009.
  5. Natural Standard: The Authority on Integrative Medicine. . Copyright © 2009. Accessed May 14, 2009.

Causes
  • HIV: HIV does not directly infect neurons (nerve cells). Instead, the virus may infect and damage the cells that surround nerves. This causes the neural insulation to unravel, as well as slow or stop the transmission of information to and from the brain. Abnormal macrophage activation is associated with neuropathy. Macrophages are white blood cells that help fight against disease. When they are abnormally activated, these cells can infiltrate and damage the myelin (the fatty sheath that coats the axons of the nerves), which eventually leads to PN.
  • Drugs: Certain HIV medications can cause peripheral neuropathy. Antivirals, including didanosine (ddI, Videx®), zalcitabine (ddC, Hivid®) and stavudine (d4T, Zerit®) are the most common causes of drug-related neuropathy. There have also been reports of neuropathy associated with the protease inhibitor indinavir (Crixivan®).
  • Other drugs that HIV patients commonly take for opportunistic infections (infections that occur in patients with weakened immune systems) may also cause peripheral neuropathy. Medications that may lead to the development of peripheral neuropathy in some patients include: dapsone, which is used to treat Pneumocystis jiroveci pneumonia (previously called Pneumocystis carinii pneumonia); isoniazid, which is used to treat tuberculosis infections; metronidazole, which is used to treat amoebic dysentery (diarrhea); and vincristine, which is used to treat cancers like Kaposi's sarcoma and non-Hodgkin's lymphoma.
  • Alcohol: Alcohol consumption can also cause peripheral neuropathy. However, the mechanism by which alcohol causes the disorder is unknown. Some researchers suggest that alcohol may have a toxic effect on nerve tissue.
  • Vitamin B12 (cobalamin) deficiency: Neuropathy can also be caused by vitamin B12 (cobalamin) deficiency, which is common among HIV patients. It is estimated that 10-35% of HIV patients are vitamin B12 deficient. Vitamin B12 plays a vital role in the metabolism of fatty acids, which are essential for maintaining myelin. Prolonged B12 deficiency can lead to nerve degeneration and irreversible neurological damage. When this occurs, the neurons can no longer transmit signals correctly. Vitamin B12 deficiency is relatively common among HIV patients. It is unclear whether low vitamin B12 levels influence HIV disease progression to AIDS, or whether they are merely a consequence of disease progression. Most HIV patients who have gastrointestinal problems are unable to adequately absorb the vitamin. Gastrointestinal problems in HIV patients are often caused by opportunistic infections or are a side of effect of antiretrovirals.

Symptoms
  • Peripheral neuropathy (PN) can be a minor nuisance or it may be disabling, causing pain that is so severe it is difficult to walk or stand. Usually both sides of the body are affected equally. Symptoms may come and go.
  • Common symptoms include tingling, burning or numbness in the hands or feet. It may also cause shooting pains throughout the body or general aching.

Diagnosis
  • General: A subjective peripheral neuropathy screen (SPNS) is the standard diagnostic tool for PN. Once a diagnosis is confirmed, the healthcare provider must determine the underlying cause in order to prescribe appropriate treatment. HIV-associated peripheral neuropathy may be the result of HIV itself, other infections, alcohol consumption or a deficiency of vitamin B12.
  • Subjective peripheral neuropathy screen (SPNS): The subjective peripheral neuropathy screen (SPNS) has been widely used to diagnose peripheral neuropathy. During the test, a healthcare provider assesses the presence of paresthesias (abnormal sensations), pain, and numbness. One study evaluated the clinical effectiveness of the SPNS. The researchers found that the SPNS had a sensitivity of 47%, a specificity of 83%, a positive predictive value of 70%, and a diagnostic efficacy of 67%. This test may be one of the most accurate diagnostic tools for PN.
  • Blood test: A blood test may be used to determine whether the patient is vitamin B12 deficient. A small sample of blood is taken and analyzed under a microscope. Healthy individuals typically have about 200-900 picograms per milliliter of blood. Values lower than 100 picograms per microliter of blood indicate a significant deficiency of vitamin B-12.
  • Nerve biopsy: A nerve biopsy may be conducted to determine the severity of nerve damage. During the procedure, a small part of the nerve from either the ankle or wrist is surgically removed and analyzed under a microscope. While the test can provide accurate information about the extent of nerve damage, it is an invasive procedure that is difficult to perform.

Treatment
  • General: In drug-induced cases of peripheral neuropathy (PN), it is recommended that patients discontinue the drug, if possible. The patient will fully recover in about eight weeks. Patients who continue to take the medication after symptoms present may suffer from permanent nerve damage.
  • HIV-associated peripheral neuropathy may also be the result of HIV itself or vitamin B12 deficiency. In such cases, treatment focuses on the underlying cause.
  • Drug treatments have not been approved to repair nerve damage in PN patients. However, several medications, including topical (applied to the skin) anesthetics, antidepressants, anticonvulsants (anti-seizure drugs), and narcotic pain relievers, are available to relieve symptoms.
  • Highly active antiretroviral therapy(HAART): Researchers believe that HIV may infect and damage the cells that surround nerves, which may lead to PN. If HIV infection is the cause of HIV-associated PN, treatment focuses on decreasing the viral load in the body. Currently, there is no cure for HIV, but highly active antiretroviral therapy (HAART) has been proven to effectively suppress the virus. HAART usually combines drugs from at least two different classes of antiretroviral drugs and it has been shown to suppress the virus.
  • The U.S. Food and Drug Administration (FDA) has approved several antiretroviral drugs to treat HIV infected individuals. These drugs fall into three major classes: reverse transcriptase (RT) inhibitors, fusion inhibitors, and protease inhibitors. In July 2006, the FDA approved a multi-class combination called Atripla®.
  • Reverse transcriptase (RT) inhibitors disrupt the reverse transcription stage in the HIV lifecycle. During this stage, an HIV enzyme, known as reverse transcriptase, converts HIV RNA to HIV DNA. There are two main types of RT inhibitors: non-nucleoside RT inhibitors and nucleoside/nucleotide RT inhibitors. Non-nucleosideRT inhibitors bind to reverse transcriptase, preventing HIV from converting the HIV RNA into HIV DNA. Approved non-nucleoside RT inhibitors include Rescriptor®, Sustiva®, and Viramune®. Nucleoside/nucleotide RT inhibitors serve as faulty DNA building blocks. Once they are incorporated into the HIV DNA, the DNA chain cannot be completed. Therefore, the drugs prevent HIV from replicating inside a cell. Approved drugs include Combivir®, Emtriva®, Epivir®, Epzicom®, Hivid®, Retrovir®, Trizivir®, Truvada®, Videx EC®, Videx®, Viread®, Zerit®, and Ziagen®.
  • Fusion inhibitors prevent the virus from fusing with the cellular membrane, thus blocking entry into the cell. The fusion inhibitor Fuzeon® is FDA-approved.
  • Protease inhibitors (PIs) interfere with the protease enzyme that HIV uses to produce infectious viral particles. PIs prevent viral replication by inhibiting the activity of protease, an enzyme used by the virus to cleave nascent proteins for final assembly of new virons. FDA-approved protease inhibitors include Agenerase®, Aptivus®, Crixivan®, Invirase®, Kaletra®, Lexiva®, Norvir®, Prezista®, Reyataz®, and Viracept®.
  • Vitamin B12: If a vitamin B12 deficiency (common in HIV patients) is causing peripheral neuropathy, vitamin B12 supplementation may be necessary. If patients are unable to absorb the vitamin in the gastrointestinal tract, the vitamin may need to be administered intramuscularly or intranasally. Treatment regimens for intramuscular injection vary. Although the Recommended Daily Allowance (RDA) of vitamin B12 is only about 2 micrograms, HIV patients often require much higher doses because they are unable to absorb the vitamin properly. Patients typically receive initial loading doses followed by monthly maintenance injections. Patients have received a daily dose of 1,000-2,000 micrograms for one to two weeks, followed by a maintenance dose of 1,000 micrograms every one to three months.
  • Topical anesthetics: Five percent Lidocaine gel (LMX®), an anesthetic gel applied directly to the skin, has been shown in clinical trials to be safe and effective for HIV-positive patients with painful neuropathy. LMX® is available with a doctor's prescription.
  • Antidepressants: Tricyclic antidepressants, such as amitriptyline (Elavil®) and nortriptyline (Pamelor®), have been used to treat HIV-associated peripheral neuropathy. These drugs, which are available by prescription, have been shown to increase the brain's transmission of nerve signals. These drugs may help reduce symptoms of the disorder since the disease occurs when there is a slowing or stopping the transmission of information to and from the brain. It is important that low doses of these drugs be used at first, with a slow buildup to the recommended daily doses.
  • Some anti-HIV protease inhibitors and non-nucleoside analogues can either increase or decrease the levels of tricyclic antidepressants in the blood. Therefore, patients should consult their healthcare providers before taking antidepressants.
  • Anticonvulsants: Anticonvulsants (anti-seizure drugs) are normally used to treat epilepsy, a neurological disorder that causes seizures. However, since these drugs help calm the central nervous system, including the part of the nervous system responsible for processing pain, they have been suggested as a possible treatment for peripheral neuropathy. Anticonvulsants, such as carbamazepine (Epitol® and Tegretol®) and phenytoin (Dilantin®), have been used to treat symptoms of HIV-associated peripheral neuropathy, according to anecdotal evidence.
  • Some antiviral drugs, including some protease inhibitors and non-nucleoside analogues may either increase or decrease the amount of anticonvulsants in the blood. Therefore, patients should consult their healthcare providers before taking anticonvulsants.
  • Narcotic pain relievers: Patients who suffer from severe pain (extreme difficulty walking or standing) may benefit from treatment with narcotic pain relievers such as morphine, oxycodone, codeine, or meperidine. These drugs are generally used in combination with tricyclic antidepressants or antidepressants. While it is safe to use narcotic pain relievers for short-term treatment, they may become highly addictive if used long-term. These drugs can also cause side effects, including nausea, vomiting, and sleepiness. Therefore, patients are encouraged to consult their healthcare providers regularly while they are taking narcotic pain relievers.
  • Some antiretrovirals drugs, including some protease inhibitors and non-nucleoside analogues, can either increase or decrease the amount of narcotic pain relievers in the blood. Therefore, patients should consult their healthcare providers before taking narcotic pain relievers.
  • Non-drug treatments: Minor pain symptoms may be managed without pain medications. Patients are encouraged to wear looser shoes, soak their feet in ice water, and avoid standing or walking for long periods of time to reduce pain.

Integrative therapies
  • Strong scientific evidence:
  • Alpha-lipoic acid: Many studies have shown that alpha lipoic acid (ALA) is an effective treatment for neuropathy associated with diabetes or cancer treatment. Additional research is needed to confirm the effects of ALA on other types of neuropathy.
  • Avoid if allergic to ALA. Use cautiously with diabetes and thyroid diseases. Avoid with thiamine deficiency or alcoholism. Avoid if pregnant or breastfeeding.
  • Good scientific evidence:
  • Magnet therapy: The use of magnets to treat illness has been described historically in many civilizations. In modern times, magnetic fields play an important role in Western medicine, including use for magnetic resonance imaging (MRI), pulsed electromagnetic fields, and experimental magnetic stimulatory techniques. Preliminary data suggest possible reductions in symptoms of neuropathy such as foot burning, numbness, tingling, and walking-induced foot pain with the use of static magnetic shoe insoles. Effects are reported to take three to four months to be perceived. Additional high-quality research is necessary before a firm conclusion can be drawn.
  • Avoid with implantable medical devices, such as heart pacemakers, defibrillators, insulin pumps, or hepatic artery infusion pumps. Avoid with myasthenia gravis or bleeding disorders. Avoid if pregnant or breastfeeding. Magnet therapy is not advised as the sole treatment for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven methods. Patients are advised to discuss magnet therapy with a qualified healthcare provider before starting treatment.
  • Unclear or conflicting scientific evidence:
  • Acupuncture: There is currently insufficient evidence on which to base recommendations for use of acupuncture in HIV associated peripheral neuropathy.
  • Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, and neurological disorders. Avoid on areas of the body that have received radiation therapy and during pregnancy. Use cautiously with pulmonary (lung) diseases, such as asthma or emphysema. Use cautiously in elderly or medically compromised patients, diabetics, and in patients with a history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.
  • Aloe vera: Clear gel from the pulp of Aloe vera leaves has been used on the skin for thousands of years to treat wounds, skin infections, minor burns, and other skin conditions. Although aloe has been suggested as a possible treatment for HIV infection, further research is needed before a firm conclusion can be made.
  • Avoid if allergic to aloe or other plants of the Liliaceae family (garlic, onions, and tulips). Avoid injecting aloe. Do not apply to open skin, surgical wounds, or pressure ulcers. Avoid taking by mouth with diarrhea, bowel blockage, intestinal diseases, bloody stools, or hepatitis. Avoid with a history of irregular heartbeat (arrhythmia), electrolyte imbalances, diabetes, heart disease, or kidney disease. Avoid taking by mouth if pregnant or breastfeeding.
  • Alizarin: Limited available evidence suggests that alizarin may be of benefit in the treatment of viral infections. Additional research is needed in this area.
  • Avoid if allergic or hypersensitive to alizarin or any plants in the Rubiaceae family. Alizarin may be toxic and should not be handled for long periods of time, rubbed in the eyes, or eaten. Avoid if pregnant or breastfeeding.
  • Antineoplastons: Antineoplastons are substances found in human blood and urine. Preliminary study reported increased energy and weight in patients with HIV who were treated with antineoplaston AS2-1, as well as a decreased number of opportunistic infections and increased CD4 cell counts. However, this evidence cannot be considered conclusive. Currently, there are drug therapy regimens available for HIV with clearly demonstrated effects (highly active anti-retroviral therapy), and patients with HIV are recommended to consult with their physicians about treatment options.
  • Avoid if allergic or hypersensitive to antineoplastons. Use cautiously with high medical or psychiatric risk. Use cautiously with an active infection due to a possible decrease in white blood cells. Use cautiously with high blood pressure, heart conditions, chronic obstructive pulmonary disease, liver disease/damage, or kidney disease/damage. Avoid if pregnant or breastfeeding.
  • Astragalus: Antiviral effects have been reported in early studies for HIV. Additional research is warranted.
  • Avoid if allergic to astragalus, peas, or any related plants or with a history of Quillaja bark-induced asthma. Avoid with aspirin or aspirin products or herbs or supplements with similar effects. Avoid with inflammation (swelling) or fever, stroke, transplant or autoimmune diseases (like HIV/AIDS). Stop use two weeks before surgery/dental/diagnostic procedures with a risk of bleeding and avoid use immediately after these procedures. Use cautiously with bleeding disorders, diabetes, high blood pressure, lipid disorders or kidney disorders. Use cautiously with blood-thinners, blood sugar drugs, or diuretics or herbs and supplements with similar effects. Avoid if pregnant or breastfeeding.
  • Beta sitosterol: Beta-sitosterol is found in plant-based foods, such as fruits, vegetables, soybeans, breads, peanuts, and peanut products. It is also found in bourbon and oils (such as olive oil, flaxseed, and tuna). Due to data that suggest immune modulating effects of beta-sitosterol and beta-sitosterol glucoside, these sterols have been studied in combination in the treatment of HIV. Larger populations of patients with HIV should be evaluated in randomized controlled trials to draw any conclusions.
  • Avoid if allergic or hypersensitive to beta-sitosterol, beta-sitosterol glucoside, or pine. Use cautiously with asthma or breathing disorders, diabetes, primary biliary cirrhosis (destruction of the small bile duct in the liver), ileostomy, neurodegenerative disorders (like Parkinson's disease or Alzheimer's disease), diverticular disease (bulging of the colon), short bowel syndrome, celiac disease, and sitosterolemia. Use cautiously with a history of gallstones. Avoid if pregnant or breastfeeding.
  • Bitter melon: Laboratory studies have shown that a protein in bitter melon called MAP30 may have antiviral activity against HIV. However, this has not been studied in humans. Further research is needed before a firm conclusion can be made.
  • Avoid if allergic to bitter melon or members of the Curcurbitaceae (gourd or melon) family. Avoid ingesting bitter melon seeds. Avoid with glucose-6-phosphate dehydrogenase deficiency. Use cautiously with diabetes, glucose intolerance, or with hypoglycemic agents due to the risk of hypoglycemia (low blood sugar). Avoid if pregnant or breastfeeding.
  • Blessed thistle: Laboratory studies report no activity of blessed thistle against herpes viruses, influenza, or poliovirus. Effects of blessed thistle (or chemicals in blessed thistle called lignans) against HIV are not clear. Human research of blessed thistle as a treatment for viral infections is lacking.
  • Blessed thistle is generally considered to be safe when taken by mouth in recommended doses for short periods of time, with few reported side effects such as birth defects, bleeding, breathing problems, bruising, cancer of the nose or throat, increased production of stomach acid, itching, kidney disease, liver toxicity, skin rash, stomach discomfort, stomach ulcers, and vomiting. Allergic reactions to blessed thistle including rash may occur, as well as cross-sensitivity to mugwort and Echinacea. Cross-reactivity may also occur with bitter weed, blanket flower, Chrysanthemum, coltsfoot, daisy, dandelion, dwarf sunflower, goldenrod, marigold, prairie sage, ragweed or other plants in the Asteraceae/Compositae family. Avoid if pregnant or breastfeeding.
  • Boxwood: Trials have been conducted for SPV30 (extract of boxwood, Arkopharma, France) to evaluate its potential effectiveness for HIV/AIDS. Rigorous clinical study is needed to confirm these early study results.
  • Avoid if allergic or hypersensitive to boxwood, its constituents, or any plants in the Buxaceae family. Use cautiously with HIV or AIDS. Avoid if pregnant or breastfeeding.
  • Carrageenan: Carrageenan-based gels may reduce HIV transmission during sexual intercourse and have been investigated for safety and acceptability in published studies involving healthy females. Overall, studies suggest that carrageenan is not associated with abnormal genital clinical findings or severe side effects, and is considered acceptable for use by females and their male partners. Additional research is needed to better determine the role of carrageenan for HIV infection prevention.
  • Use oral carrageenan cautiously in infants. Use cautiously in patients with, or at risk for, cancer. Use cautiously in patients treated with azoxymethane or nitrosomethylurea. Use cautiously in patients with gastrointestinal, immune, inflammatory, or bleeding disorders, or in patients with low blood pressure or diabetes. Use cautiously intravaginally. Use cautiously in patients using antilipemic agents. Use cautiously in combination with any oral medication, as the fiber in carrageenan may impair the absorption of oral medications.
  • Chiropractic: Chiropractic care focuses on how the relationship between musculoskeletal structure (mainly the spine) and bodily function (mainly nervous system) affects health. There is currently not enough reliable scientific evidence to conclude the effects of chiropractic techniques on CD4 cell count or quality of life in patients with HIV/AIDS.
  • Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders or migraines. Use cautiously with the risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis, or arthritis. Avoid with agents that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.
  • Coenzyme Q10: Coenzyme Q10 (CoQ10) is produced by the body and it is necessary for basic functioning of cells. CoQ10 levels decrease with age. There is limited evidence that natural levels of CoQ10 in the body may be reduced in people with HIV/AIDS. Reliable scientific research showing that CoQ10 supplements have any effect on this disease is currently lacking.
  • There are currently no documented cases of allergy associated with Coenzyme Q10 supplements, although rash and itching have rarely been reported. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use cautiously with history of blood clots, diabetes, high blood pressure, heart attack, or stroke. Use cautiously with anticoagulants (blood thinners), antiplatelet drugs, blood pressure drugs, blood sugar drugs, cholesterol drugs, or thyroid drugs. Avoid if pregnant or breastfeeding.
  • Cranberry: Limited laboratory research has examined the antiviral activity of cranberry. Further research is warranted in this area.
  • Avoid if allergic to cranberries, blueberries, or other plants of the Vaccinium species. Sweetened cranberry juice may affect blood sugar levels. Use cautiously with a history of kidney stones. Pregnant and breastfeeding women should avoid cranberry in higher amounts than what is typically found in foods.
  • DHEA: DHEA (dehydroepiandrosterone) is a hormone that is secreted by the adrenal glands. Although some studies suggest that DHEA supplementation may be beneficial in patents with HIV, results from different studies do not agree with each other. There is currently not enough scientific evidence to recommend DHEA for AIDS, and other therapies are more proven in this area.
  • Avoid if allergic to DHEA. Avoid with a history of seizures. Use cautiously with adrenal or thyroid disorders. Use cautiously if taking anticoagulants, or drugs, herbs, or supplements for diabetes, heart disease, seizures, or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.
  • Flaxseed and flaxseed oil: Flaxseed and flaxseed oil/linseed oil are rich sources of the essential fatty acid, alpha-linolenic acid (omega-6). While flaxseed has been used to treat HIV/AIDS, no strong evidence supports its use and no recommendation can be made without further research.
  • Flaxseed has been well tolerated in studies for up to four months. Avoid if allergic to flaxseed, flaxseed oil, or other plants of the Linaceae family. Avoid with prostrate cancer, breast cancer, uterine cancer, or endometriosis. Avoid ingestion of immature flaxseed pods. Avoid large amounts of flaxseed by mouth and mix plenty of water or liquid. Avoid flaxseed (not flaxseed oil) with history of esophageal stricture, ileus, gastrointestinal stricture, or bowel obstruction. Avoid with history of acute or chronic diarrhea, irritable bowel syndrome (IBS), diverticulitis (inflammation of the diverticula, small sacs in the intestine's inner lining), or inflammatory bowel disease (IBD). Avoid topical flaxseed in open wounds or abraded skin surfaces. Use cautiously with history of a bleeding disorder or with drugs that increase the risk of bleeding (such as anticoagulants and non-steroidal anti-inflammatories). Use cautiously with high triglyceride levels, diabetes, mania, seizures, or asthma. Avoid if pregnant or breastfeeding.
  • Green tea: Green tea is made from the dried leaves of Camellia sinensis, a perennial evergreen shrub. Green tea has a long history of use, dating back to China approximately 5,000 years ago. Green tea, black tea, and oolong tea are all derived from the same plant. Preliminary research suggests that green tea may decrease viral load in carriers of the human T-cell lymphocytic virus. Additional well-designed controlled research is needed before a conclusion can be made.
  • Avoid if allergic or hypersensitive to caffeine or tannins. Use cautiously with diabetes or liver disease.
  • Healing Touch: Healing touch (HT) is a combination of hands-on and off-body techniques that influence the flow of energy through a person's biofield. Data from small preliminary studies are insufficient to support any recommendations for or against use of HT in HIV/AIDS patients. Studies of better design are needed before any conclusions can be reached.
  • HT should not be regarded as a substitute for established medical treatments. Use cautiously if pregnant or breastfeeding.
  • L-carnitine: L-carnitine may be beneficial in AIDS treatment by increasing proliferation of mononuclear cells and increasing CD4 counts. Additional study is needed to make a firm recommendation.
  • Studies on the use of L-carnitine for peripheral neuropathy are of poor quality, and the results are controversial. Further research is needed before a firm conclusion can be made.
  • Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.
  • Licorice: Early studies suggest that glycyrrhizin may inhibit HIV replication in patients with AIDS. However, human reports are lacking. Additional study is needed to make a conclusion.
  • Avoid with a known allergy to licorice, any component of licorice, or any member of the Fabaceae (Leguminosae) plant family. Avoid with congestive heart failure, coronary heart disease, kidney or liver disease, fluid retention, high blood pressure, hormonal abnormalities or with use of diuretics. Licorice can cause abnormally low testosterone levels in men or high prolactin or estrogen levels in women. This may make it difficult to become pregnant and may cause menstrual abnormalities.
  • Massage: Evidence is limited and mixed as to whether massage may be of benefit for immune functioning or health services utilization in people with HIV/AIDS.
  • Avoid with bleeding disorders, low platelet counts, or if on blood-thinning medications (such as heparin or warfarin/Coumadin®). Areas should not be massaged where there are fractures, weakened bones from osteoporosis or cancer, open/healing skin wounds, skin infections, recent surgery, or blood clots. Use cautiously with history of physical abuse or if pregnant or breastfeeding. Massage should not be used as a substitute for more proven therapies for medical conditions. Massage should not cause pain to the client.
  • Meditation: Various forms of meditation have been practiced for thousands of years throughout the world, with many techniques originating in Eastern religious practices. A common goal is to attain a state of "thoughtless awareness" of sensations and mental activities occurring at the present moment. More studies are needed to establish how meditation may be useful as an adjunctive therapy in HIV/AIDS patients.
  • Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professionals before starting a program of meditation and they should explore how meditation may or may not fit in with their current treatment plans. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and it should not be used as the sole approach to illnesses.
  • Melatonin: Melatonin is a neurohormone produced in the brain. There is a lack of well-designed scientific evidence to recommend for or against the use of melatonin as a treatment for AIDS. Melatonin should not be used in place of more proven therapies, and patients with HIV/AIDS should be treated under the supervision of their healthcare professionals.
  • Based on available studies and clinical use, melatonin is generally regarded as safe in recommended doses for short-term use. There are rare reports of allergic skin reactions after taking melatonin by mouth. Use cautiously with bleeding disorders, seizure disorders, or if taking drugs that increase the risk of bleeding.
  • Mistletoe: Treatment of HIV patients with mistletoe has been conducted in Europe since the beginning of the AIDS epidemic. Treatment seems to be tolerable with minimal side effects reported. Mistletoe may assist in inhibiting disease progression. However, not all mistletoe preparations have shown equal effects. Further study is needed before a firm conclusion can be made.
  • Avoid if allergic or hypersensitive to mistletoe or to any of its constituents. Anaphylactic reactions (life threatening, shock) have been described after injections of mistletoe. Avoid with acute, highly febrile, inflammatory disease, thyroid disorders, seizure disorders, or heart disease. Use cautiously with diabetes, glaucoma, or with cholinergics.
  • Prayer/distant healing: Prayer can be defined as a "reverent petition," the act of asking for something while aiming to connect with God or another object of worship. Limited study of prayer in patients with HIV/AIDS reports fewer new AIDS-related illnesses and hospitalizations. However, due to methodological problems, these results cannot be considered conclusive.
  • Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and it should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches and require an open dialog between patients and caregivers.
  • Psychotherapy: Psychotherapy, especially supportive psychotherapy, may reduce depression in HIV positive patients. It may also help with treating substance abuse when used in combination with prescription medicine. Supportive-expressive group therapy may also have concomitant improvements in CD4 cell count and viral load. More research is needed in this area, especially to determine the best type of psychotherapy.
  • Psychotherapy, especially cognitive behavioral therapy, may improve functioning in people with HIV-related peripheral neuropathic pain. More research is needed.
  • Psychotherapy cannot always fix mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases symptoms may get worse if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression.
  • Reiki: Reiki instruction may help reduce pain or anxiety in HIV/AIDS patients, but results are unclear.
  • Reiki is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Use cautiously with psychiatric illnesses.
  • Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. Mental health and quality-of-life improvements have been seen in preliminary studies of HIV/AIDS patients. These findings suggest the need for further, well-controlled research.
  • Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and it should not delay the time to diagnosis or treatment with more proven techniques.
  • Selenium: Selenium is a mineral found in soil, water, and some foods. Selenium supplementation has been studied in HIV/AIDS patients, and some reports associate low selenium levels with complications such as cardiomyopathy. It remains unclear if selenium supplementation is beneficial in patients with HIV, particularly during antiretroviral therapy.
  • Avoid if allergic or sensitive to products containing selenium. Avoid with history of non-melanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.
  • Shiitake: Based on preliminary studies, lentinan from shiitake mushroom may increase CD4 counts and may be effective as an adjunct therapy in HIV. Further well-designed studies are needed to confirm these results. Side effects have been reported and more proven therapies are recommended at this time.
  • Avoid if allergic or hypersensitive to shiitake mushrooms. Avoid if pregnant or breastfeeding.
  • Sorrel: There is currently not enough evidence on the proposed antiviral effects of sorrel. More research is needed.
  • Avoid large doses of sorrel because there have been reports of toxicity and death. This may be because of the oxalate found in sorrel. Many sorrel tinctures contain high levels of alcohol and should be avoided when driving or operating heavy machinery. These sorrel formulations may cause nausea or vomiting when taken with the prescription drugs metronidazole (Flagyl®) or disulfiram (Antabuse®). Avoid if pregnant or breastfeeding.
  • Spiritual healing: Distant healing and prayer have been used in patients with HIV/AIDS. There is conflicting evidence in this area and more study is needed.
  • Spiritual healing should not be used as the only treatment approach for medical or psychiatric conditions, and should not delay the time it takes to consider more proven therapies.
  • TENS (Transcutaneous electrical nerve stimulation): Transcutaneous electrical nerve stimulation (TENS) is a non-invasive technique in which a low-voltage electrical current is delivered through wires from a small power unit to electrodes located on the skin. Several case reports and a small number of controlled trials report improvements in pain symptoms in people with peripheral neuropathy or nerve damage. However, these studies have not been well designed or reported, and additional research is needed before a firm conclusion can be drawn regarding effectiveness.
  • Avoid with implantable devices such as defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously in patients with decreased sensation and with seizure disorders. Avoid if pregnant or breastfeeding.
  • Therapeutic touch: There is currently not enough evidence that therapeutic touch may benefit immunity or emotional well-being in HIV/AIDS patients. More research is needed.
  • Avoid with fever or inflammation, and on areas of the body with cancer.
  • Thymus extract: Thymus extracts for nutritional supplements are usually derived from young calves. Preliminary evidence found no improvement in HIV progression to AIDS or immunostimulation, although some immunological activity was noted in a non-randomized controlled trial. Additional study is needed to better understand the effects of thymus extract for HIV/AIDS.
  • Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy or hormone therapy. Avoid with thymic tumors, myasthenia gravis (neuromuscular disorder), or untreated hypothyroidism. Avoid if pregnant or breastfeeding. Thymic extract increases human sperm motility and progression.
  • Traditional Chinese medicine (TCM): Traditional Chinese medicine (TCM) is a broad term that refers to many different treatments and traditions of healing. They share a common heritage of technique or theory rooted in ancient Chinese philosophy (Taoism) that dates back over 5,000 years. TCM herbs are a popular complementary therapy in HIV/AIDS. However, study results conflict. More studies are needed before the potential benefits of TCM herbs in HIV/AIDS can be established.
  • Chinese herbs can be potent and may interact with other herbs, foods, or drugs. Consult a qualified healthcare professional before taking. There have been reports of manufactured or processed Chinese herbal products being tainted with toxins or heavy metal or not containing the listed ingredients. Herbal products should be purchased from reliable sources. Avoid ma huang, which is the active ingredient in ephedra. Avoid ginseng if pregnant or breastfeeding.
  • Turmeric: Turmeric is a perennial plant native to India and Indonesia, and it is often used as a spice in cooking. Based on early research, turmeric may help treat various viral infections. Several laboratory studies suggest that curcumin, a component of turmeric, may have activity against HIV/AIDS. However, reliable human studies are lacking in this area. Well-designed trials are needed.
  • Avoid if allergic or hypersensitive to turmeric (curcumin), yellow food colorings, or plants belonging to the Curcuma or Zingiberaceae (ginger) families. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, or gallstones. Use cautiously with blood thinners (e.g. warfarin). Use cautiously if pregnant or breastfeeding.
  • Vitamin A: Vitamin A is a fat-soluble vitamin that is derived from two sources: retinoids and carotenoids. Retinoids are found in animal sources (such as the liver, kidney, eggs, and dairy products). Carotenoids are found in plants like dark or yellow vegetables and carrots. The role of vitamin A in the prevention, transmission, or treatment of HIV infection is controversial and not well established. A clear conclusion cannot be formed based on the available scientific research.
  • Avoid if allergic or hypersensitive to vitamin A. Vitamin A toxicity can occur if taken at high dosages. Use cautiously with liver disease or alcoholism. Smokers who consume alcohol and beta-carotene may have an increased risk for lung cancer or heart disease. Vitamin A appears safe in pregnant women if taken at recommended doses. Use cautiously if breastfeeding because the benefits or dangers to nursing infants are not clearly established.
  • Zinc: Patients with HIV/AIDS, especially those with low zinc levels, may benefit from zinc supplementation. Some low quality studies cite reduction in infections, enhanced weight gain, and immune system function, including increased CD4 and CD8 cells, with use of zinc. However, other low quality studies conflict with these findings. Further research is needed before a conclusion can be made.
  • Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. While zinc appears safe during pregnancy in amounts lower than the established upper intake level, caution should be used since studies cannot rule out the possibility of harm to the fetus.
  • Fair negative scientific evidence:
  • Ozone therapy: Ozone molecules are composed of three oxygen atoms. Ozone exists high in the earth's atmosphere and absorbs radiation from the sun. Reports of using ozone for medicinal purposes date to the late 19th Century. Laboratory studies have shown the HIV virus to be sensitive to ozone, but high-quality human studies are lacking. A preliminary study measured the safety and effectiveness of ozone-treated blood in the treatment of HIV infection and immune disease. Ozone therapy was not shown to enhance immune activation or diminish the HIV virus.
  • Autohemotherapy (a therapy in which blood is withdrawn from the body) infused with ozone, and then replaced into the body), has been associated with transmission of viral hepatitis and with a possible case of dangerously lowered blood cell counts. Insufflation of the ear carries a risk of tympanic membrane ("ear drum") damage, and colon insufflation may increase the risk of bowel rupture. Consult a qualified health professional before undergoing any ozone-related treatment.
  • St John's wort: Anti-viral effects of St. John's wort have been observed in laboratory studies, but were not found in available human study. Multiple reports of significant adverse effects and interactions with drugs used for HIV/AIDS, including protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs), suggest that patients being treated for HIV/AIDS should avoid this herb. Therefore, there is evidence to recommend against using St. John's wort in the treatment of patients with HIV/AIDS.
  • Avoid if allergic or hypersensitive to plants in the Hypericaceaefamily. Rare allergic skin reactions like itchy rash have been reported. Avoid with immunosuppressant drugs (such as cyclosporine, tacrolimus, or myophenic acid). Avoid with non-nucleoside reverse transcriptase inhibitors or protease inhibitors. Avoid with organ transplants, suicidal symptoms, or before surgery. Use cautiously with history of thyroid disorders. Use cautiously with drugs that are broken down by the liver, with monoamine oxidase inhibitors (MAOI) or selective serotonin reuptake inhibitors (SSRIS), digoxin, or birth control pills. Use cautiously with diabetes or with history of mania, hypomania, or seasonal affective disorder (SAD). Avoid if pregnant or breastfeeding.

Prevention
  • HIV patients who have vitamin B12 deficiency may be encouraged to take vitamin B12 supplements. Absorption of vitamin B12 in HIV-positive people with gastrointestinal problems is typically poor unless the vitamin is injected or taken in a form that will dissolve in the mouth and be absorbed across the mucous membranes. Evidence is lacking that preventative treatment with vitamin B12 supplements will reduce the likelihood that peripheral neuropathy will develop in patients who are receiving didanosine (ddI, Videx®) or zalcitabine (ddC, Hivid®) antiretrovirals.
  • HIV patients should avoid frequent or high amounts of alcohol consumption.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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