Nausea, Vomiting and Appetite Loss

Figuring out the cause

Nausea, or feeling sick to your stomach, is something everyone feels sometimes. It can also lead to vomiting, or throwing up. Sometimes it passes after a few hours or within a day. When nausea causes repeated vomiting over time, it can result in serious malnutrition, dehydration and imbalances in some of the normal chemical compounds, called electrolytes, in the blood.

Appetite loss, or not feeling the urge to eat, can accompany nausea but it can also occur on its own. It may be harder to notice, but it can be even more serious when it leads you to not consume enough nutrients to maintain your health.

Keeping notes about your symptoms can help your healthcare provider know how to successfully address them. Keep track of:

• How often you feel nauseated each day, how long the nausea lasts, and whether you vomit on any of these occasions. If the feeling persists through much of the day, note this. Also keep track of how many days of the week the nausea occurs.
• Any pattern you notice about when nausea occurs. Does it occur when you first wake up, after you take your medications, when you smell food, when you begin eating, after meals, or in response to anything else you can identify?
• Any ways that nausea changes how or when you take your HIV medications. Do you end up skipping doses of your antiretroviral drugs or other medications because you feel too nauseated to take them? Do you have difficulties keeping down your medications because of vomiting? If so, how often does this occur?
• Everything you eat and drink over the course of a few days. This can help you and your healthcare provider assess whether your total intake of calories and nutrients is sufficient for optimal health.

While medications can cause nausea, vomiting or appetite loss, there are other things that can also cause these symptoms. Your healthcare provider should run blood tests and carry out an overall medical workup to see if liver problems, infections, hormone deficiencies or other medical conditions are contributing to your nausea or appetite loss. There are many possible causes for these symptoms. Often, more than one factor will be contributing to them.

Not all healthcare providers approach the problems of nausea, vomiting and appetite loss seriously. If you feel your symptoms are not being effectively managed, tell your healthcare provider that the symptoms are affecting your life and your ability to eat a healthy diet. Emphasize that the search for a cause or causes of your symptoms must continue.

Infections

Appetite loss and nausea can be caused by infections. Almost any infection can result in decreased appetite, along with fever, fatigue and generally feeling lousy. Nausea can be caused by certain infections, including many common bacterial and viral ones. The organisms that cause food poisoning will often cause sudden and sometimes severe nausea, so food poisoning should always be considered.

Some infections and cancers that can also cause nausea in people living with HIV include H pylori gastritis, secondary syphilis, cryptococcal meningitis, cryptosporidiosis and other parasitic infections, viral hepatitis, Mycobacterium avium complex (MAC), severe toxoplasmosis and lymphoma. Some of these are uncommon in people whose HIV is well treated, but it is always important to consider the possibility that an infection is contributing to nausea and appetite loss. If so, take all necessary steps to diagnose and properly treat it.

Antiretroviral drugs, other medications and supplements

Nausea is a common side effect of antiretroviral drugs, pain medications, cancer chemotherapies, radiation and many other therapies. Virtually all the currently available antiretroviral drugs can cause nausea, though some (for example, protease inhibitors) are more likely to cause this problem than others. It is also one of the symptoms of the rare abacavir hypersensitivity reaction. 

Drugs used to treat many infections can cause nausea. One nausea-causing drug that people with low CD4 counts can be taking is the antibiotic Bactrim/Septra, used to prevent Pneumocystis pneumonia and some other infections. Most people tolerate this drug well, but some people develop significant nausea and may need to switch to a different preventative drug.

Pain medications cause nausea in a large percentage of people. If these drugs are possibly contributing to your nausea or appetite loss, discuss possible alternatives with your healthcare provider. Cancer chemotherapies and radiation can also cause very severe nausea and it is very important to address this in order to continue to treat the cancer.

Some people experience nausea from certain supplements, such as fish oil. This can be more common if the supplement is taken on an empty stomach. Pharmacists advise people to watch for side effects when they start a supplement and not to begin taking a new supplement when they are changing any other medication.

Liver problems, pancreatitis, testosterone deficiency and depression

Testing to assess the possibility of liver problems is important in determining the cause of nausea and appetite loss. If tests show the possibility of liver damage, therapies to support the liver and reverse damage or prevent its worsening are important to counter nausea and appetite loss.

People living with HIV are at an increased risk of developing pancreatitis, and this risk may be higher when people take certain medications or drink a lot of alcohol. If severe abdominal pain starts suddenly and is accompanied by nausea and vomiting that lasts several hours, especially after eating or an alcohol drinking binge, then pancreatitis is a possibility. These cases need immediate medical attention. 

Testosterone deficiency is common in people living with HIV and can lead to decreased appetite. It is important to have your testosterone level tested for many reasons. If testing shows your levels to be low, testosterone replacement therapy may improve your appetite. 

Depression occurs in some people living with HIV and, when present, frequently causes appetite loss. If depression is a problem for you, it is very important to get the treatment you need. 

Changing your medications or your medication schedule

If the nausea or appetite loss you are experiencing appeared just after you began taking a new medication, your drug is a possible cause of your symptoms. If the problem doesn’t improve over the next few weeks, talk to your healthcare provider about it. In many cases, these side effects diminish or disappear after a short time on the medication. 

Another factor to consider is the timing of your medication. Consult your healthcare provider or pharmacist to determine whether taking your drug at a different time of day could help. Some drugs cause less nausea when taken with a full meal; others should be taken on an empty stomach.

Changing your eating habits

To cope with ongoing nausea or appetite loss, try changing your eating habits. Eat on a schedule and substitute smaller meals and frequent small snacks for three big meals. Allowing your stomach to remain empty for too long tends to increase nausea. This approach will also help prevent low blood sugar, which can worsen nausea. Even if you don’t feel hunger pangs by the next scheduled meal or snack, do the best you can to eat at that time. Anything that perks up your appetite and doesn’t make you feel nauseated should be tried. For example:

• Try different seasonings or sauces to find one that improves the taste of food without creating nausea.
• Ginger can be very useful for helping to control nausea. Powdered ginger in capsules, ginger ale that is made from real ginger, ginger tea or candied ginger can all be helpful.
• In cases of mild queasiness, lemon can sometimes suppress nausea. Before a meal, slice a fresh lemon and sniff it for a minute or two. Or, drink water with lemon in it before eating.
• If you have more appetite or less nausea at certain times of day, try to eat at those times. Put the focus on nourishing foods so that every bite counts.
• Smells can sometimes trigger nausea. Try making a meal out of cold foods, which tends to smell less than hot foods.
• Sip liquids through a straw to limit their smells.
• If cooking smells trigger nausea, try to stay away from the kitchen when food is been cooked; open windows and turn on fans to blow cooking odours away.
• Keep tasty snacks around so that any moment of appetite can be used to your advantage.
• Use dry and/or salty foods like crackers, bread or toast, to calm the stomach.
• Protein foods can improve nausea and sweet foods can sometimes worsen it, so avoid sweet foods at breakfast. Instead, start your day with a small amount of protein such as a hard-boiled egg or leftover chicken. 
• Sip cool beverages such as juice, or carbonated beverages such as fruit juice spritzers. Some people find carbonation can worsen nausea and can prefer flat or non-carbonated drinks; try both to see what works for you.
• Chew food thoroughly so the stomach can handle it more easily.
• Avoid spicy foods, fried foods, high-fat meats, sauces or gravies, sour cream, caffeine-containing beverages and alcohol.
• Eat bland foods like broth, miso soup, mashed potatoes, rice, oatmeal, toast, naan or plain yogurt.
• Eat sitting up and try to remain in an upright position for at least two hours after eating. This can help reduce the tendency to vomit. If you experience recurrent vomiting, it is very important to rebalance your electrolytes. 

Countering nutrient deficiencies 

Ongoing nausea or appetite loss can lead to a vicious cycle where reduced food intake results in inadequate levels of nutrients. That lack of nutrients creates malnutrition-induced appetite loss, which results in continuing reduced nutrient intake. When this cycle occurs, it is necessary to restore your body’s nutrient levels to normal. The solution usually involves a combination of appetite boosters, high-nutrient foods and supplementation.

A multivitamin mineral supplement can help increase micronutrient intake. If nausea makes taking pills difficult, liquid multivitamins are an option. The micronutrient deficiency most known for causing appetite loss is zinc. Although zinc is contained in most multivitamins, you can restore levels more quickly by adding it as a separate supplement (talk to your healthcare provider or pharmacist). Caution needs to be taken with zinc as high doses can cause nausea and diarrhea. People often add a copper supplement (5 mg daily, taken at a different meal) to reduce the risk of heart problems. However, if levels of copper are too high, it can lead to liver damage. Talk to your healthcare provider and pharmacist before starting a copper supplement.

Drinking a liquid meal may seem a lot easier than eating a meal Try a home-made blended soup or a nutrient-rich, high-calorie smoothie. Experiment by blending together the following ingredients:

• Regular milk or dairy alternatives, like rice or coconut milk, plus non-acidic fresh fruits like banana, apple, peaches or blueberries
• Coconut oil or nut butter, if you need more calories
• Vanilla. almond, ginger or other natural flavorings for variety
• Frozen fruit (instead of fresh) or ice, if you like an icy smoothie
• High-quality protein powder, if you need more protein Among the best of the available protein powders are the whey protein products. Just don’t overdo protein powders. Remember that too much protein can actually strain the kidneys and cause diarrhea.

If you don’t want to create your own supplement, look for supplemental drinks that are low in sugar, use predominantly medium chain triglycerides (MCTs), are moderately high in good-quality protein and high in calories overall.

Anti-nausea and appetite-stimulating drugs

If previous suggestions fail to resolve your problems with nausea or appetite loss, it is very important to discuss with your healthcare provider or pharmacist the use of medications to counter them.

The most commonly used drug in Canada for nausea, even in hospital emergency rooms, is dimenhydrinate (Gravol and its generic equivalents). You may find that you can get effective relief from mild to moderate nausea with a children’s dose of Gravol rather than the adult dose. Using small amounts of the children’s dose also helps to avoid drowsiness. If you are taking an adult dose of Gravol and not getting relief from nausea, you should see your healthcare provider or pharmacist as soon as possible.

There are a large number of prescription medications used in the treatment of severe nausea and appetite loss. If one medication does not work, another one might. Or a combination of medications may do the trick. The best results are sometimes seen using drugs that act in different ways. For example, some drugs work by emptying your stomach more quickly, while others block the signals to and from the brain that otherwise result in nausea.

Drugs can interact with one another to cause side effects or other problems. Always ask your pharmacist to check for drug interactions with your current antiretrovirals and other medications before trying any of these agents.

Some of these anti-nausea medications can be given in different forms. For people with severe nausea that makes it difficult or impossible to keep pills down, quick-dissolve tablets, suppositories, patches, injections or intravenous infusions are important options.

One warning on medication choices: megestrol acetate (Megace) was prescribed in the past for appetite stimulation but it can suppress production of testosterone, which is already low in many people living with HIV. Testosterone deficiency can contribute to appetite loss. Talk to your healthcare provider about alternative medications that may be right for you.

Other anti-nausea agents

Studies have shown ginger to be an effective anti-nausea agent, even in chemotherapy-induced nausea. Because the anti-nausea effect of ginger requires it to be physically present in the stomach, consume it a few minutes prior to eating, drinking or taking medications. It can be taken in capsule form or as a ginger syrup that is added to water you can drink throughout the day.

Or make ginger tea by chopping or grating 30 to 45 ml (two or three tablespoons) of fresh ginger root and adding it to 250 ml (a cup) of boiling water. Simmer for five to 10 minutes and drink throughout the day. Chopped ginger root can also be added to many dishes where it will add flavour, as well as help counter nausea.

Medicinal marijuana or cannabis is effective as an appetite stimulant and anti-nausea agent, so it can be a good choice for people who need both. Preparing a healthy meal prior to using marijuana can help ensure its appetite-stimulating effects are used to the best nutritional benefit. The cannabinoid drug nabilone (Cesamet) is sometimes used for severe nausea and vomiting. Smoking marijuana can be hard on your lungs, so some people prefer consuming it in a food (edibles). All cannabinoid agents can leave people feeling “stoned.” There may be a link between marijuana use and the medical condition called psychosis. People with a predisposition to psychosis should first talk to their healthcare provider before using marijuana.

Acupuncture and acupressure

Both acupuncture, which uses needles at energy points in the body, and acupressure, which uses physical pressure on energy points, can be helpful for nausea. Acupressure bands, most commonly sold as remedies for motion sickness, are one simple way to get help with nausea. These bands are available at many pharmacies, health food stores and from some health practitioners.