Ribaviron absorption and dietary fiber

I know when I first started tx and asked for advice, lots of people told me to drink lots of water, have fat with my Riba, and  either I read it elsewhere, or a few people here told me to not have much fiber at the same time I took my Riba. I can't find anything lately... especially my brain, so if anybody on here knows where I got this from, I would really appreciate it if you would remind me!

(:-)

[IMstacie]

Yes fiber is not a good idea at the same time you take your Riba.  Not so much with fruits & veggies. It's the bulk fiber that could cause the interference.  Also, taking antacids with the riba can also limit absorption.

Bill1954 once posted a website from Schering-Ploughs PEG-Intron prescribing info regarding the effects of food on absorption of ribavirin - may want to check it out:

http://www.spfiles.com/pipeg-intron.pdf

[carol411]

I found this on this site, but I don't remember how I got there.

Carol



DON'Ts on HCV TX

DON’Ts on HCV TX


Saying Yes    Do not say yes to people, if you do not have the strength to do something with them or for them. Learn to say NO.

Tanning Beds    Stay away from tanning beds. Due to the photosensitivity caused by tx drugs, serious burns and blisters have been experienced.

Sun exposure    Stay out of the sun as much as possible. Be watchful! Due to photosensitivity caused by tx drugs, serious burns and blisters have been experienced. Wear a high SPF sunscreen, preferably an organic product and a hat.

Milk Thistle    Might interfere with drugs. It speeds up liver metabolism, resulting in medication possibly being prematurely eliminated from the blood stream. Google ‘milk thistle drug interaction’ for more information. Milk thistle can also produce allergic reactions among people with ragweed, marigold, chrysanthemum and daisy allergies

Grapefruit        The naringin/naringenin in this citrus fruit might interfere with drugs. It can enhance the amount and/or the length of time medications stay in the blood stream. Google ‘grapefruit drug interaction’ for more information. Other citrus fruits like bitter orange, sour oranges as Seville oranges, pomelo and tangelo have a similar effect. Sweet oranges, tangerines and lemons are considered safe.

Medications    Do not take without your doctor’s consent. Certain drugs can be damaging to your liver or even fatal, when taken together with other drugs, so ALWAYS consult with your doctor.

Supplements    Do not take without your doctor’s consent. Even supplements can interact with medications, and be sure they do NOT contain any iron. Some vitamins are stored in the fat of the body (vitamins A, D, E, K) and can become toxic, if taken in high doses over a prolonged period of time. Extra amounts of them should be avoided to prevent overload and toxic complications.

Iron                Do NOT take iron supplements, they should be avoided to prevent overload and toxic complications in the liver. Discuss this with your doctor.

Raw Seafood    Liver disease puts you at an increased risk for the bacterial infection vibrio vulnificus.

Alcohol            It is damaging to the liver and interferes with medications.

Fatty/Fried Foods      It is better to avoid these, as they are difficult for your liver to digest.

Bulk Fiber        Do not take BULK FIBER like psyllium husk, bran, flax, clay, etc. within 1 hour before or after any medications, as they will bind with them and transport them out of your body.
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[Bill1954]

Hi Stacy,

That link takes you to the full PDF prescribing info file for Schering Plough; it works but the file is bulky. I hand typed an excerpt here for reference:

“Both AUC and C-MAX increased by seventy percent when Rebetol Capsules were administered with a high fat meal: (841 kcal, 53.8 g fat, 31.6 g protein, and 57.4 g carbohydrate) in a single-dose pharmacokinetic study.”

As far as dietary fiber and it’s interaction with our combo treatment, I only vaguely remember someone posting about that, and I’m not sure there was any reliable data supporting it, other than anecdotal reports. That doesn’t mean it’s untrue, just that I don’t have any info either way.

Best to you both,

--Bill

[spectda]

Thats a lot of fat. maybe we should drink a cup of oil with each dose. anyone have suggestions of what to eat that won't kill you while you're trying to save your life!

[Bill1954]

Carol, I think you might have gotten that from the lower right-hand side of this page, in the box titled ‘most viewed health pages’:

http://www.medhelp.org/health_pages/Hepatitis/DONTs-on-HCV-TX/show/183?cid=64

I don’t know for sure how that page was sourced, although I think ‘Marcia” might have placed it there; I say that from memory, though, and hopefully the author will chime in with their thoughts.

Unfortunately, just being on one of Medhelp’s pages doesn’t lend itself to authority :o). If someone has any peer reviewed, published data on this topic, it’d be interesting to see it.

--Bill

[Bill1954]

Dude, I know; break out the onion rings and jumbojacks w/cheese :o)!

[Trinity4]

You don't have avoid foods with fiber while on tx.  

[spectda]

I guess my measly avocado and some cheese with a dose ain't gonna cut it! LOL

[Bill1954]

Normally, we’d suggest that cup of oil to be 10 w 40, but with summer in full swing now, I’m almost certain your doctor would advise 5 w 30. And no, I can't support that with published data...

Enjoy!

[willing]

no time to worry about  a little arteriosclerosis or DM when you're gunning for SVR!  jokes aside, common sense might help: taking the riba with whatever fats are part of your normal, steady-state  diet will help absorption. Adding fats seems a doubtful gain; you're probably better off adding more rbv  and peeing most of it out than taking less and leaving your body to sort out where to dump those  841cals of packing material

[spectda]

Good point. Since I'm in a trial for boceprevir i don't get any input on dosing. I'm hoping the big guns (boce) will do it.

[Bali05]

funny how we get tested for everything from viral load to thyroid to lfts ect...., yet a

serum riba concentration test is next to impossible to come by.

hmmmmm

[spectda]

I agree, it must be a very expensive test.

[Bali05]

why would it be more expensive than a PCR ?

Viral load is like a genetic test so I get it , but simply to establish

Ribavirin concentration in your blood why would that be more expensive

than to establish your iron concentration for example ?

[Bill1954]

I don’t think this requires novel technology; I believe HPLC (high performance liquid chromatography) testing was used by the Swedish team Lindahl to assay plasma ribavirin in that high dose riba study we referenced earlier.

My guess is that the issue at hand is FDA approval and the limited need for this test; would a lab be able to recover approval costs for limited need? Here’s an article from wiki about HPLC technology; I think it’s frequently used in this country for things like drug testing, etc:

http://en.wikipedia.org/wiki/High-performance_liquid_chromatography

--Bill

[willing]

I believe Bill is right on target - it's not a cost or difficulty issue but lack of evidence that measuring rbv plasma concentration contributes to decision making. A recent free access review is here
http://www.ncbi.nlm.nih.gov/pubmed/18931138
note they make the point that most studies have found linear correlation between HgB level and serum concentration, so from a patient perspective, test early, test often.

Another recent ('09) meta-analysis set out to evaluate whether on-tx serum rbv assays were effective and concluded there was too much disagreement to justify testing:

"Numerous trials show an association between ribavirin con- centration and virologic response.12-15,23,28,33-35,37,40,41,43,44,47,51,53-55
However, many trials also show no association between rib-
avirin concentration and virologic response.33,34,36,37,44,48-50,52,54
Additionally, while many trials show a correlation between
ribavirin concentration and the development of anemia,26,39,40,42,45,47,51,53,55 others show the opposite.12,38,39,44,49,54"

http://www.ncbi.nlm.nih.gov/pubmed/19920162

personally, I'd like to know. On this subject, it's interesting that Roche is taking on a couple of high-dose rbv trials , see

http://clinicaltrials.gov/ct2/show/NCT00662220

with a whopping 25-29 mg/kg. Given my lurking concerns about rbv as a carcinogen that seemed an encouraging sign, but look at the length of the exclusion criteria!  

[GSDgirl]

Back to the fiber issue................I didn't know that Riba should be taken with fat and didn't pay attention to my fiber intake or any of the other stuff mentioned and cleared geno 2B, was UND at 12 weeks.  I couldn't even force a gallon of water a day, I don't know who came up with the gallon amount but there is a formula that is weight specific (I don't know it but someone here does)

I ate what I could and drank as much as I could.  It worked for me and a few others.

Denise

[nygirl7]

Dont take fiber pills / drinks after your riba it is strictly common sense that tells you there is a difference between eating some broccoli with cheese or taking a glass of fiber products which will push things right through your system quickly.

On the second part I've always found it interesting how riba absorption would matter since Jim told me the Swedish study data and had me barely double dosing my riba - six point drop in hemo in ten days yet never cleared at week 12 and not until 24.  Interesting contraditions but I"d err on the side of caution.

[GSDgirl]

OH, I didn't mean that it was OK to take x-tra fiber supplements, never took them until recently (old age LOL)

I just figured to only take the drugs for hep, no supplements only the prescription drugs like blood pressure, anti D's and whatnot.

Denise

[Diane12855]

As to the fiber thing, I finally had a clear enough brain to do some Google searching, and the only articles I found that put the fiber consumption and Riba together were from Med Help. So, it appears to me that it isn't the issue I thought it was.

I stand corrected. Sorry about that.

[Bali05]

thanks for poiting that out.

if anybody ever finds a lab that does a serum riba concentration test please let

me know , i would do it immediately.

we have enough guess work going on as it is

nobody would have to worry about fiber intake ect.... on top of it

[Trinity4]

I don't understand why your so hell bent on finding a lab that will do a serum riba concentration test.  You're taking high dose riba without doctor supervision correct?
What would the outcome be regardless?  If your hgb were dropping significantly would you feel the high dose riba is working more effectively?  

You predosed riba for almost 6 weeks with some high dosage times so at this point either the serum level is sufficient or it's not.  You're on your sixth week of tx, can't really change it now.

Trinity

[nygirl7]

So, it appears to me that it isn't the issue I thought it was. "

Well most of our doctors told us not to take extra fiber supplements - not fiber itself as found in veggies etc. I wouldnt take it. Unless you don't worry about riba but I sure believe in the riba more than the fiber during treatment.

[Bali05]

let me explain and will keep it short  , i am on treatment and would like to have a solid

answer about the riba concentration in my blood . A month ago , now and in the future.

[mikesimon]

I saw an article about ribavirin concentration authored by physicians at the following institution so maybe you could get tested there.

Department of Infectious Diseases, University of Turin, Turin, Italy

[Trinity4]

Wow, a serum riba concentration test and the opportunity to view the Shroud of Turin.
Now that IS exciting.

[mikesimon]

Frequent monitoring may present a problem though depending on where you live and/or how much money you have.

Mike

[nygirl7]

Get anemia then you'll know it's high enough for you!   ;)

[jusjames]

i know where you can get a test , and i know someone who had one, but why bother it wont make it start working differently , its too late now really 6 wks in i would say,as the first 4 wks is when you need the impact, with the high dose you are on you will either have enough or you will never have enough if you know what i mean

[FlGuy]

In the absence of a readily available test for riba concentration you can evaluate yourself with a simple set of survey questions

Has your hemoglobin dropped more than 25% ?
Do you scream at family members without reason?
Do you talk to yourself and then forget what you said?
Have you misplaced anything in the last three days?
Have you found the missing item in a refrigerator?
Have you missed a medical appointment time by more than a day?
Has your family moved out of the house?
Have you been bitten by a mosquito that suddenly dies?
Have you gotten ready for work on a day off?
Does your tub require Draino more than once a week?
Do you itch like a heroin addict?
When you look in mirror do you say “Holy Shite”


More than 10 ‘Yes’ --- Riba is about right
Less than 8  ‘Yes’ --- Dose is right, you forget to take sometimes
Less than 6 ‘Yes’ --- You ain’t on treatment

[Diane12855]

My Riba is about right then.

Great test!

[can-do-man]

Good one......

[spectda]

25 grams of fat in a small bag of peanuts. I am having one with each riba dose. It makes me kind of nauseous though!

[Diane12855]

I prefer the avocado. Much easier on the stomach and more mono-saturated fats.

[jusjames]

just been talking to the person who had the test very interesting to hear the course of action they took..

[spectda]

You are very illusive! LOL What action did they take?

[Bali05]

so is the serum riba concentration test available in the US...... ?

[FlGuy]

I think Jusjames is in the UK somewhere.

[nygirl7]

with the high dose you are on you will either have enough or you will never have enough if you know what i mean "

You do realize that taking all the riba in the world won't matter - your body can only handle a certain amount, get to a high concentration then it's all overboard and a waste of time.  Once your hemo drops like mine did (six points in 10 days) you learn that really you are only sabotaging your treatment and it didn't matter AT ALL.

I wish I had listened to the doctors instead of one person on an internet forum.  The incredible amounts of epogen I was on weekly to maintain the riba level put my life much more at risk than the liver damage and treatment.

It's amazing what stupid things people can do in the quest to be cured.  Overdosing on medication is NOT the the way to go.  It is dangerous.

[jusjames]

sorry had to go
basically the subject had the test and it was a bit low so they increased the dose by 200 mg increments from 1000 to 1600 at which point anemia was experianced and the concentration level was suddenly good.
location of test? sweden

[spectda]

Personally I would never just start taking extra meds. I would find a qualified hepatologist to treat me and help find the right dose, and monitor for safety if I was in the situation of needing to treat again.

[willing]

flguy: great list. I must be in good shape for my next round - according to the list I'm already at the right dose and I haven't even taken my first pill..

bali: on a practical level, best approach at the moment might be to have a vial drawn and stored at -80 while you look for a lab. Here's a recent French paper that compared assays across three labs:
http://www.ncbi.nlm.nih.gov/pubmed/19412142
Their sample collection was:
"After 15 minutes of centrifugation of blood samples at
1733g and 4C, serum was aliquoted and stored at -80C in
brown 1.5 mL polypropylene tubes until analysis."
so basically draw a couple of ml, spin and freeze.

I think Mike's suggestion is a good one : once you've collected your vials contact studies that have done serum rbv concentration (there are lots) and look for a local lab. University hospitals are a good bet.

From that free-access Morello'08 review linked above,

http://www.ncbi.nlm.nih.gov/pubmed/18931138

it looks like the window between not-enough and too-much is pretty narrow:

"what is the therapeutic range for ribavirin? The chances of response increase with greater ribavirin plasma concentrations. According to all studies reviewed, we propose a target concentration of at least 2–2.5 mg/L to maximize the achievement of SVR. Unfortunately, ribavirin plasma concentrations gt 2.5 mg/L are associated with significant rates of haemolytic anaemia"

[Gee704]

Thanks for the laugh!
It's nice to know we have our humor to keep us going.

BTW...My Riba is about right!

[nygirl7]

Personally I would never just start taking extra meds. I would find a qualified hepatologist to treat me and help find the right dose, and monitor for safety if I was in the situation of needing to treat again. "

This was way back right after the Swedish study was done so  I read it and listened to someone.  It was the lesson that taught me 'one study does not the truth make' and the reason I try to point out to people to make sure they are listening to their doctor and not making things up as they go. For my weight I should have had 800  but I begged up to 1,000.  I should have left it at that 1200 - 1600 a day was just WAY too much and didn't accomplish anything that the 1,000 would have.

Lesson hard learned!

[Bali05]

obviously many people react very differently to the meds
anemia is a sx of riba but not everyone gets anemic
and not everyone who gets anemic SVRs
from my observation people with an intial rapid hgb drop are more likely to require
rescue drugs
i had a 2.6g drop hgb so far and it happend slowly despite increased dosages

just to make something clear , i am not blindly and rectlessly  overdosing
instead i early on did small incremental increases with tightly monitored weekly
CBCs. You really can`t do much more short of getting the serum test.
You know how much I like to do tests...
Now , what does it all mean , only time will tell but I do see a lot of slow responders
despite rapid hgb drop.
I decided to go up on my riba dosing (at least in the beginning) because I see studies
for geno 1 that showed better SVR rates.

how about riba with scrambled eggs in the am. It has fat and protein and no fiber.

[Bali05]

thanks,

best part in all of this is that in the little pamphlets that come with the meds it says

something like the exact actions of ribavirin and peg against hcv are unknown.

got to keep myself reminding of that once in a while.

[tashka]

Yes, this is true. Precise mechanisms of action for both interferon and ribavirin are unknown.