Riba and fiber question...

[Kathy73]

I start SOC on Thursday and saw in a thread today that fiber may inhibit the absorbsion of riba. I'm on the Atkins style diet and eat alot of fiber. Does the fiber matter when the pills are taken or at all times? Anything else I should know about riba?

[Kathy73]

Thanks, that was what I was interested in. I do eat a high fiber diet because of being overweight and trying to lose. High fiber foods (and I'm not talking about fiber supplements) help me to feel full and eat less.

[jmjm530]

I won't try and compete with you on the topic of insulin resistance, but I do have confidence in my medical team's grasp of the issue. They encouraged me to eat whatever I could, fat and all, and I am not alone in this. I'm sure my frequent blood monitoring, including glucose level monitoring, gave them the confidence to make these recommendations. Not to mention my significant weight loss and improved lipid profile which are not representative of insulin resistance. The issue of pre-treatment insulin resistance and steatosis is different and I have encouraged people both to lose weight and eat healthy both before and after treatment.

-- Jim

[CoWriter]

"so if iI have wrongly assumed you see my diet as fat filled, you are incorrect"

You said "fat helps with nausea" and "you need fat for nausea" and I said fat causes nausea and that I have never heard anybody recommend fat for nausea at any of the seminars/lectures I have attended...and that includes several by Dr Poordad  from Cedars, Dr Hassanin from San Diego, Dr Hillebrand from Scripps, and Dr Rossaro from UCDavis.  (I may even know your nurse,  It sounds like we hang out at the same places)

However, I never said that I saw your diet as "fat filled".  As a matter of fact, I said that you should eat whatever you can tolerate to prevent further weight loss.

Best of luck to you.

[CoWriter]

"so then what is the harm of taking your riba with a high fat meal as long as: (1) You can tolerate it; and (2) you are being properly medically supervised with no red flags."

Because a high fat diet can cause insulin resistance.  And insulin secretion increases when insulin sensitivity decreases.   So you end up with hyperinsulinemia.....and large levels of insulin, make interferon ineffective.

Plus....

In healthy volunteers, insulin resistance can be detected after one injection of interferon.  In HCV patients, interferon induces insulin resistance in the first two weeks, (mainly owing to a decrease in hepatic glucose uptake caused by proinflammatory cytokines induced by interferon).  Even though it is a transitory effect....what do you think would happen if during that period of "transitory" IR the person eats a high fat diet?  

The insulin resistance would increase.....which would cause hyperinsulinemia....which would make the interferon ineffective.  



"Thus, insulin resistance emerges as the most important host factor in the prediction of response in non-diabetic patients treated with the best available option -peginterferon plus ribavirin. Interestingly, insulin resistance has been found a common denominator to the majority of features associated with difficult-to-treat patients."


http://scielo.isciii.es/scielo.php?pid=S1130-01082006000800006&script=sci_arttext

[Deb_c430]

Take Ribavirin with food
AVOID GREASY HIGH FAT or highly seasoned foods.
Frequent small meals
Encourage oral hygiene
Flat soda, ginger products, folic acid, and B12.
Light exercise.  "

Uhm never said take with huge amounts of fat.  I do thank you for your info though, this part got cut off.  I again feel you are reading into my words what I did not say,  I have repeated a few times,  that food has a lot of natural fat in it anyway.  

Thank you = to not live on fat.

[jmjm530]

Hopefully, we're in agreement that one-size-does-not-fit-all here.

For some (a person whose name rhymes with "New York Pearl" comes to mind) an ice cream diet may do the trick.

For others, maybe they can get away with let's call it a healthy diet.

Then for those, like myself, who were blessed with an interferon-induced eating disorder from hell -- well, those folks just have to eat wha they can.

The key seems to be that things are supervised by a good medical team.

I'm sure if something with my insulin when totally out of whack, my medical team would have been brought to my attention (I know you would have had you been my NP LOL) and dietary measures would probably be attempted. But with me, and many others, nothing in that area was out of whack and in fact my lipid values were ironically the best I've ever had.

So when you say for some people "a high fat diet can really hurt their treatment", hopefully there is a check and balance at work, that being their medical team watching over things -- and hopefully nothing I've said will be construed to interfere with that.

In the sprit of reconcilliation, I've tried to tactfully avoid the riba-with-fat bioavailability issue, but it's hard to help myself completely, so one last thought. Since I think we both agree that the studies are inconclusive in terms of clinical implications -- so then what is the harm of taking your riba with a high fat meal as long as: (1) You can tolerate it; and (2) you are being properly medically supervised with no red flags.

Perhaps we agree on this as well as you might have thought I was trying to tell everyone to eat ham and cheese omelets on treatment. I'm not --  it's just that it worked for me, on a number of levels, and frankly those breakfasts are about the only thing I've missed from my treatment.

Good play btw ordering those sensitive tests. It's amazing how doing the right thing can get you into trouble in big organizations. I can relate...

-- Jim

[Deb_c430]

Well with all due respect,   I know her, your a name on the forum, I trust her. Though I do respect your knowledge. She is out in the field all the time.  

So what company do you work for? she is integrated care..    She also attends seminars at UCLA, Cedars, a big HCV  seminar in No Calif. and a few others, she has been very forth coming sharing new info.  Very knowledgable concerning  treatment.  

I eat a healthy diet, always have, moderation, I eat out rarely, I am Italian I like real food.  WHo grew up in California, lived in italy, over seas, I eat produce, fruits, So I tend to eat in season, I am not and never will be a vegan, or a vegatarian, THough I love fresh produce more than anything.   so if iI have wrongly assumed you see my diet as fat filled, you are incorrect,  

[CoWriter]

"And for better or worse, most treating physicans treat per drug company protocols which probably still only require a week 12 test, although I haven't checked lately."

Years ago, docs treated without biopsies, viral loads were done at week 24 and 48 and the test measured down to 650.....LOL

I used to work for an HMO that insisted we use that viral load test because the more sensitive one was, of course, more expensive.  But then I did a little "research" and found out that the HMO was capitated for viral loads.....meaning that they paid the lab a lump sum every month for doing whatever viral loads the docs ordered.  Didn't matter how many.  

So I figured.....if the cost would be the same....then why use the crappy test....LOL  And I called the lab and told them to toss out the old test and in the future only do the sensitive one that measured down to <10

When my supervisor found out what I'd done, she called me in her office and yelled at me.  It was worth it, though.....and I was very proud of myself for having thought of it....LOL


"but we will have to agree to disagree if your conclusion is that it doesn't matter how much fat you take with your riba."

That wasn't really the point I was trying to make.  I have no problem with taking Riba with some fat.....it's the high fat intake I have a problem with.  

It sort of encourages people to keep thinking that "the ice cream diet is the best out there for people on treatment".

It is not....and for some people, a high fat diet can really hurt their treatment.    

In other words, it was my daily "insulin resistance lowers SVR" rant....LOL

[Marcia2202]

To get back to the fiber.... I am pretty sure the fiber which was referred to in what you read, was bulk fiber, like psyllium husk and the like. The ones used for cleansing the bowels. They tend to lock in everything in their path and transport it out of the system fast. You can eat your riba with fiber like bread, rice and cereals etc.

I take mine with a tablespoon of virgin coconut oil and some food or fruit.

Marcia

[jmjm530]

CO: but you're letting me off easy..
---------------------------------------------------

Yes because I've got other things to do today and all your captialized letters are starting to hurt my eyes :)

BTW do you know where the original riba ingestion instructions came from, i.e. "Take with or without food". They simply were copied from early study protocols were participants were told to "take with or without food". Nothing scientific, the label was just parroting an arbitrary study protocol. Not sure where the "take with food" came from, maybe because the drug companies finally realized that no sane clinician was telling their patients to take riba on an empty stomach. LOL.

If there is a point here it's that the drug companies are often way behind in what they recommend as opposed to what some clinicians recommend from work in the field. And for better or worse, most treating physicans treat per drug company protocols which probably still only require a week 12 test, although I haven't checked lately.

This isn't to say your patients don't get top care, but we will have to agree to disagree if your conclusion is that it doesn't matter how much fat you take with your riba. And mind you, I'm not 100% convinced due to lack of study data, but I think it's reasonable to conclude (until studies to the contrary) that the higher bioavailability studies may carry over to real world treating.

[nygirl7]

Positive I read a study/article that explainned how the riba bound to the fat in order to get best absorption a long time back but of course didn't save it to show it (since I've been SVR two years now).

it made perfect sense to me and I'm glad I did it.  Of course, I did not nor couldn't have eaten that much on treatment that any meal could have ever been called a "large" meal.

Perhaps as in all things moderation is key.  It seems to really work and I still think taking your riba will your meals 2x a day at breakfast and dinner - with some items that do contain fat.......is the best course of action there could be.

I never did a diet so I don't know what Atkins is exactly (thought it was the no bread diet but how would I really know) but I still think that the ice cream diet is the best out there for people on treatment.

(PS I still do wish I could go back though now to the days of treatment when losing weight was so easy just so I could have one of Jim's breakfasts...I gotta say they always made me so jealous and I'd drool but alas - it was hard enough just getting down a yogurt smoothie some mornings).       ;)






'FUDGICLES RULE!!!!!!!!!!!!!!

[CoWriter]

I expected to totally get beat up for opening my mouth (by everybody, I don't mean just you)....but you're letting me off easy....LOL

I think ; )

Co

[CoWriter]

"Actually I disagree, my RN who works for the Drug company and GI both recomend fat for nausea"


Imagine that.  I'm one of those RN's too.  And I can tell you that no speaker program for any drug company says to use fat for nausea.  Protein helps nausea.  

For somebody like you who has lost so much weight and can't afford to loose any more, the recommendation is certainly to eat whatever you can tolerate, and that includes fat.... to prevent further weight loss and hopefully increase your energy level.....but not as a way of treating nausea.  


From the last Schering's Speaker's program meeting....I quote....


"Nausea/Vomiting Non-Pharmacological Management

Take Ribavirin with food
AVOID GREASY HIGH FAT or highly seasoned foods.
Frequent small meals
Encourage oral hygiene
Flat soda, ginger products, folic acid, and B12.
Light exercise.  "

[jmjm530]

Fat aggravates GERD...it doesn't make it better like some people think.
--------------
Not sure if having GERD for 52 weeks straight makes me an expert, but I do know a bit about it.

The most common GERD triggers are cigarettes, chocolate, tomato sauce and citric fruits. Too much fiber also can aggravate GERD, as can exercise, stress and a bunch of other stuff like having your belt too tight.

GERD is very individual and one person's trigger may not be another's. For me, fat was not a trigger unless I ate high-premium ice cream. Not sure if it was the fat content or the cream that did it.

I have read that more frequent, lower fat meals are good for GERD. That simply didn't work for me on treatment. Again, it's a very individual thing and the patient will know a lot more about their triggers than a book.

-- Jim

[jmjm530]

CO: I was just making a point.  A high-fat meal DECREASES Riba absorption.  I think I've got it straight.
-------------------------------
I read your "point" quite different in the context of your discussion and anyone interested can re-read your post and come to their own conclusion. Yes, the riba absorption is decreased BUT the bioavailability is INCREASED which is the point I was making. In the future I will be more careful using "absorption" in the lay sense without inversely tying it in with bioavailability.

CO: 1 egg has 5 grams of fat.  I doubt that you ate 10-11 eggs to consumme the amount of fat per meal suggested by the study.  
-
My treatment breakfast was ham and cheese omelet (cooked in oil or butter), home fries, a couple of orders of buttered toast and jelly. Do the math and I'm but pretty sure you'll find 53 grams of fat.

--------------------------------------------
Just want to reinterate that I'm not suggesting my breakfast to anyone, because as mentioned previously there were reasons other than riba absorption why I ate like this.
Gastric and weight loss issues for one. Taste alteration for another where I couldn't hardlylook at most "healthy" foods.

Of interest is that while on this diet I had the best lipid scores ever, because of the way the interferon reacted with my system.

So, you just can't say something that isn't healthy off treatment will have similar effects on treatment. Cholesterol off treatment on a much better diet would be around 200 without statins. On treatment around 140.

Had my blood work or other signs gone out of whack. And should my doctor have suggested altering my diet, then I would have tried. But to the contrary. I was urged to eat anything I could get down in order to keep the weight up. And my doc -- no pun intended -- was not a light weight :)

-- Jim

[Deb_c430]

Actually I disagree, my RN who works for the Drug company and GI both recomend fat for nausea,  We are again not talking crisco by the spoon fulls,  We are talking healthy levels.

My RN only treats HCV patients, stays very current with  all studies,  I do not have heart burn, nor gerd,  

[CoWriter]

"Even with out the riba question you need some fat in your diet"

I know.  Fat is a source of energy.  But only 30% of a person's total calories each day should come from fat.....not 50% as suggested in the Riba study.  



"it does help with nasuea"

"If for no other reason, you need fat for naseaua."


Actually, fat causes nausea.

Too much fat delays emptying of the stomach, stimulates extra acid secretion and may cause reflux, a back-up of stomach acid and food into the esophagus that causes heartburn. Fat may also cause diarrhea, nausea, or stomach discomfort.

Fat aggravates GERD...it doesn't make it better like some people think.

[Deb_c430]

I will say this in simple terms, food is not my favorite right now, I am easily made nauseous, I have went from 122 lbs, to 98 during this txt, fat or no, i will get down what ever I can, when I can.  

[CoWriter]

"First, there seems to be some confusion regarding bioavailability versus rate of absorption. Several times you refer to the slower absorption of ribavirin with a high fat meal as if it’s a negative."


On a previous post, you said......

"As mentioned, taking riba with a high-fat snack (high-fat meal better) has been shown to increased riba absorption"

I was just making a point.  A high-fat meal DECREASES Riba absorption.  I think I've got it straight.


"And while the studies aren’t perfect – more on that later – taking riba with a high-fat meal has been shown to increase bioavailability up to 70%."

Compared to people who were fasting.  That means that we don't know whether bioavailability would be 69% or 71% or whatever if people eat a regular, non high-fat meal because they didn't look at that.  They compared people who ate a high fat meal to people who ate nothing.  

And they looked at bioavailability after ONE dose of Riba.  Bioavailability after multiple dosing may be totally different.


"I’d take my riba with a high fat meal because I think there's reasonable info that it will give you an edge and I will also eat to survive (cheese omelets and all :)  "

1 egg has 5 grams of fat.  I doubt that you ate 10-11 eggs to consumme the amount of fat per meal suggested by the study.  

I agree, if it means survival, it's better to eat junk than to eat nothing at all.  At that point, getting calories is the important thing, doesn't matter where they come from.

But I can't agree with suggesting people starting treatment eat 54 grams of fat twice a day (as suggested by the study) to maybe increase Riba bioavailability.  Not when up to two thirds of them may have insulin resistance and many of them have steatosis.

A high fat diet promotes oxidative stress, steatohepatitis, hyperglycemia, hepatic insulin resistance, hyperinsulinemia, an increase in CYP2E1, and cytokine-induced beta-cell death.

I suppose since hyperinsulinemia makes interferon ineffective, then we wouldn't have to worry about the bioavailability of Riba.

[Deb_c430]

I spoke to my Drug company nurse about this,  The point is you do need fat, if you are on a fat free diet, it does help with nasuea,   Fat is found in most foods, I am not speaking Mcdonalds! I am talking a salad with olive oil, a small piece of meat cooked in olive oil,  Nuts, icecream.  Even with out the riba question you need some fat in your diet, skin, hair, ect.

If for no other reason, you need fat for naseaua.   For skin, for hair,

When I first started visiting here, my VL actually went up!  Ny and jim both suggested a higher fat diet, it worked.  

[jmjm530]

Thanks for joining the riba discussion.

I’ve read the Medscape article you referenced and if I had to treat again today, I’d still take my riba with a high fat meal for a number of reasons.

First, there seems to be some confusion regarding bioavailability versus rate of absorption. Several times you refer to the slower absorption of ribavirin with a high fat meal as if it’s a negative.

In fact, slower absorption is often associated with HIGHER bioavailabity which to simplify  means how much of the drug taken becomes available.

“The clinician is concerned primarily with bioavailability rather than absorption.”
http://www.accessmedicine.com/content.aspx?aID=935828

And while the studies aren’t perfect – more on that later – taking riba with a high-fat meal has been shown to increase bioavailability up to 70%.

The second reason is because some (not all) of us find taking riba with fat produces less gastric discomfort. I, like many others, had constant gastric problems and I'm sure the riba didn't help.

And lastly, because many of us, including myself, had signficant weight loss during treatment and therefore needed the fat as calories.

This is a conversation we’ve had previously, and I’ve felt you have been both dismissive about what I contend is a non-preventable issue in many (not all) of us.

You seem to think that dietary intervention can both prevent weight loss and the grossly altered taste/appetite sensations that many of us have. I disagree.

Prior to treating, I had a relatively healthy Mediterranean style diet supplemented with protein shakes. I loved fish, vegetables, tofu, etc.

During treatment, the thought of a vegetable or Tofu would give me the Willies. I know that “willies” isn’t a scientific term but believe me many of us got it from even thinking about certain foods. For that reason, eating was more survival than anything else during treatment. Yes, I would loved to have eaten healthier --- and used healthier fats – but I couldn’t. Many of us can't.
-----------------------------------
As to Antacids, your Medscape quote for some reason became truncated but the complete quote says that the bioavailability was reduced by 14%. The figure you included (Cmax) is not as important because it doesn't measure steady state. Is it unlikely to be of clinical significance as stated (but not in caps as you suggested) I really don't know. But again, I would in no way take the chance and chase my riba with Maalox, when there are better alternatives such as PPIs (like Nexium) and H-2 blockers like Pepsid, Zantac, etc.
---------------------

I do understand the study data is inconclusive in this area and that almost all citations end with the caveat that no clinical implications can be drawn. That’s not unusual because the studies have been quite limited. So we read the studies and we make up your own mind. Draw our own implications.

And to come back to the beginning,  to do it all over again – g*d forbid :) -- I’d take my riba with a high fat meal because I think there's reasonable info that it will give you an edge and I will also eat to survive (cheese omelets and all :) )because that was the only way I was able to eat on treatment and equally imporant, it was the only way I was able to stay on treatment due to significant weight loss.

Lastly, want to clear up your comment on what someone posted regarding riba needing fat to find to it. Not that you attributed that statement to me, but since I'm the only one you referenced in your two posts that confusion may exist. Someone else said that. I didn't.


-- Jim

[Kathy73]

Thank you all so much for your wonderful information. It is truly appreciated.

[CoWriter]

One last thing......

As per the info on Riba pharmacokinetics......

"Coadministration with an antacid (containing magnesium, aluminum, and simethicone, Mylanta) reduced the bioavailability of ribavirin.  Cmax (Maximum Concentration) WAS REDUCED BY 3%.  THIS CHANGE IS UNLIKELY TO BE OF CLINICAL RELEVANCE. "


http://www.medscape.com/viewarticle/416602_2

[epiphiny]

Thanks for that, one of the more comprehensive posts on this topic I have seen.  And I am really glad you decided to post it as I spent ages looking for info a few months back with limited success. I noticed that some of the study you quote is also in the latest Copegus Medicine Info Sheet ie increased bioavailabilty of riba when taken with food as against fasting.

Anyway, for a while I tried to really up my fat intake with my riba meals and all I really succeeded in doing is making myself feel very fat and bloated and adding a few kilos!!  In the end I have taken the 'in moderation approach' and have included some healthy fats in my breakfast and dinner and have gone back to my normal weight.

Thanks again,

Epi.