Management of Protease Inhibitor-Associated Diarrhea [Sherman DS and Fish DN. CID 2000; 30: 908]: The authors reviewed the very practical issue of diarrhea associated with protease inhibitors, primarily nelfinavir, but others as well. Most studies dealing with this topic are limited to abstracts and use of non-specific agents. Agents that some evidence of efficacy include oat bran, psyllium, loperamide, calcium carbonate, SP-303 and pancreatic enzymes. A list of these agents and the suggested regimens are summarized below:

Treatment of PI-Associated Diarrhea
Product	Regimen	Disadvantages	Cost/month
Oat bran	1,500 mg bid	Bloating, flatulence	OTC* $3.60
Psyllium	1 tsp. qd or 2 bars qd	Bloating, flatulence, drug interactions	OTC $3.96
Loperamide	4 mg, then 2 mg up to 16/d	Abdominal pain	OTC $9.60
Calcium	500 mg bid	Abdominal pain, nausea	OTC $3.00
SP-303	500 mg qid	-	OTC $54.00
Pancreatic enzymes	1 - 2 tabs with meals	-	$30 - $111.00
*Over the counter

Comment: Diarrhea is a frequent complication of antiretroviral agents, especially nelfinavir. Most physicians have a favorite method to deal with this, but the science in support of specific strategies is relatively weak, in part reflecting the fact that the pathophysiologic mechanism is not well defined. Five of the six agents reviewed are available over-the-counter and most are relatively inexpensive with the exception of SP-303 and pancreatic enzymes. Dietary changes, including the avoidance of caffeine, the avoidance of milk and milk products (possible), and increased intake of dietary fiber are also important. When intervention is required, the authors recommend initiating treatment with an inexpensive agent that has published evidence of efficacy such as oat bran, psyllium, or calcium. posted 8/11/2000