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?

[nygirl7]

You really want to take the riba with fat - it needs the fat to bind to or you will just lose it out of your system. Riba must build up and get to a certain set level in your body - absorption is crucial.  I personally would make sure that I was taking it twice a day with something that was loaded with fat no matter what you eat for the rest of the day.

You also don't want to take it with Tums or Maalox or something like that because it will have the same negating effect.

[Kathy73]

Thanks. Say with some cheese? Would that have a high enough fat content? What times of day would be the best?

Also, I've been reading the forum for awhile now and think you give wonderful advice.

[nygirl7]

Kathy,

I always took mine with breakfast and dinner because that was about 12 hours apart or so (7am/7pm) and it helped me to always remember them too.  I don't know if a piece of cheese is really enough but whatever you can do it better than nothing for sure! I never ever ate breakfast before in my life but had to make myself do it for the pills. Some days even if it was just a yogurt smoothie I'd take that just to have something for the meds to bind to.  However ice cream was a great dinner (even when I was too sick to eat) and I soon became fast friends with Mr. Ben & Jerry ;) of course on Atkins that's probably not such hot advice.....but it was the one time in my life I felt I could get away with it!

Stuff like peanut butter has natural fat oils that are good too, even though in large quantities it would be fattening but at least it's something healthful for you (and you aren't going to eat the whole jar of the stuff LOL).

I'm sure the other guys will come in and give you some good tricks that they used shortly.  I was never a breakfast eater so that meal was always tough for me but if you are going to eat your 'meal meals' on a diet - I'd try and aim for at least two hours before to take the pills. I THINK that is what they advise if you have to take antacids but obviously the farther way the better.

(It just wouldn't be fun to get up at 4am to take them at all though! ;)

Debby

[Kathy73]

So I should take the pills at least 2 hours before the meal. I wouldn't mind that because I don't like to eat when I first get up. I could take the pills with some cheese or peanut butter and then eat my breakfast two hours later? Just want to make sure. I don't want to mess this up before I even start!

[copyman]

take the riba within 1/2 hour "after" eating" or in the middle of a meal that has some fat content. It really don't matter when you take the riba. once the riba has built up in your system you could actually take all the pills at once,  but that may upset your stomach so 2 times a day is best.  but by no means does it have to be evenly spaced apart. as long as you get the full amount in everyday. good luck

[epiphiny]

Here's a link to a similar thread that has more suggestions on what to eat with your riba:

http://www.medhelp.org/posts/show/645030?personal_page_id=387&post_id=post_3482306

Epi :)

[konyha]

Doesn't the Atkins Diet include fat? if so, as others have explained, taking the Riba should be no problem with meals based on that kind of diet - if this is the case.

Do you mean that you supplement fiber - or include fiber enriched foods in your diet? If so, a fiber drink or food with fiber at lunch or a few hours before or after the RIBA should not inhibit the absorption of fiber or inhibit the absorption of the RIBA.

I take my RIBA with some type of fat Am and PM - and since my eating habits have slightly changed and declined (along with regularity) since treatment, my GI says that Pysllium or Herba Prima (both soluble and insoluble fiber) is ok as long as I drink A LOT of water.

[meNtoby]

THATS what I forgot to buy at the store!  More PEANUT BUTTER~!  dang

[merryBe]

peanut butter and sesame butter are high in iron so don't get carried away with these.

everybody on tx also needs to watch for iron overload and demand the test be done..which not all clinics do automatically.

as your HGB drops from the Riba/Inf your free tranferrin rises, and if you eat red meat and other things high in iron you can end up with damaging amounts.  The iron gets deposited in liver, brain and elsewhere. The oxidation the excess iron causes leads to free radicals and hence hepatic cancer.  So you want to watch that.

eat plenty of fiber, but eat your riba meals with low fiber for best absorption.
particularly at the beginning of treatment you want to get the best absorption of that drug...and get UND as soon as possible so nothing that binds to the riba should be eaten. I either ate a little cheese and bread...or half a klondike bar...or a few bites of oatmeal....just something to coat the tummy...so the drugs don't chew it up....

[epiphiny]

I try to eat my fibre in the middle of the day.  For breakfast I have oatmeal with Virgin Coconut Oil in it and full fat organic acidopholis yogurt, I then follow that with a teaspoon of fish oil for omega 3 and 6.  Sometimes I also add a chunk of cheese.  I have regular dinners and just try to add some healthy oil for cooking or as a salad dressing to keep the fat content up.  If I'm concerned that there wasn't enough natural fat in my meal I take a couple of teaspoons of tahini with my riba, or have some ice cream.  At first I thought I would put on weight but I seem to sitting pretty stable at th weight I started treatment on.

[Deb_c430]

the magic word, ice cream! You do need the fat,  you will find, a lot of foods have fat in them naturally,   Tx is the one time you should not worry over much oh what you eat.

The fat trick helped me,  it does work, it also helps with nasuea,  NY is right you need it.

Whole grains are ok, nuts, ect.   but to much fiber may mess you up around wk 20,

Best of luck!

Deb

[jmjm530]

It's fiber supplements like Metamuscil, bran, and flax that can be the problem and not fiber-rich foods unless it's something very fiber fortified like Uncle Sam's Cereal, for example. Also avoid antacids like tums, maalox, mylanta, Gaviscon, etc. within a few hours of the riba. PPI's like Nexium are OK and so are H-2 blockers like Pepsid AC, Tagament, Zantac, etc. Just be careful with combos (H2 Blockers plus antacids) like Pepsid Complete and treat them like a simple antacid, in other words don't take at same time as the riba.


As to Atkins, I don't consider that even a high fiber diet, so would not be concerned. May I ask why you're on Atkins btw? If it's for weight loss, you may find SOC your friend in that regard, but as many here have found, be careful what you wish for because sometimes we lose more weight than we wish. Also, many have found sticking to a diet difficult on tx as our taste buds and appetite change, so just try and be flexible and take it as it comes as to diet.

As mentioned, taking riba with a high-fat snack (high-fat meal better) has been shown to increased riba absorption. I took mine with my two big meals of the day but that was easy because I only at twice a day on treatment. I took them just before my first bite but taking them during the meal (or right after) should also work. Just found taking them just before the first bite was easier to remember. Riba does not have to be taken 12 hours apart according to several doctors (and a riba researher) I spoke to as it has a very long half life.  I ate bkfast between 10-12 and dinner between 4-6 so my riba doses were sometimes only 4 hours apart. The main thing is that I took the riba with my meals which had fat in them.

Peanut butter and sesasme butter are fine with the riba and restricting iron really has more to do with taking iron supplements (don't unless your doc says to) than iron rich foods. Some have been told to avoid iron cookware.

-- Jim

[CoWriter]

"You really want to take the riba with fat - it needs the fat to bind to or you will just lose it out of your system. "

That's not true.  Multiple-dose ribavirin half-life is 298 hours.

Every time I hear you guys tell somebody else to take their Riba with a high-fat meal, I tell myself, "Stay out of it.  Disagreeing will do nothing for your popularity"...LOL.  But it bothers me because I've been to many conferences and lectures and I don't remember being told that the Riba should be taken with a high-fat MEAL.  Taking it with food yes, but not with 54 grams of fat.  If I told people to do that, I would probably go to hell....LOL


First of all, let's see what the drug company that did the study means by "a high-fat meal"..... ( 53.8 grams of FAT, 31.6 grams of PROTEIN, and 57.4 grams of CARBOHYDRATE.  A total of 841 calories per meal).

53.8 grams FAT = 482 calories.  If you have 2 high fat meals a day, that would give you a total of 1682 calories.....964 calories from fat.  Over 50% of the total calories would come from fat.  Considering that only 30% of a person's total calories each day should come from fat, that would be a very unhealthy diet.  

If you're a diabetic, you're allowed a total of 1800 calories a day.  So that means that after eating your two high fat meals, you'll have 118 calories left for your third meal and two snacks....which may cause your blood sugar to be out of control.

What are you guys going to eat to make your meal "high fat"?  Did you say TWO tablespoons of peanut butter?  Hmmm.....that's only 16 grams of fat.....so you'll have to eat at least 6 tablespoons.  Or a Big Mac, fries and 2 tablespoons of peanut butter.....Twice a day!  

What they're suggesting is ridiculous and unhealthy.  

But let's continue......I did a little research on the effects of food on Riba bioavailability....


"Two studies have been carried out to assess the effect of food (ie, a high-fat breakfast) on the bioavailability of SINGLE oral doses of ribavirin.  An initial study by ICN Pharmaceuticals, Inc. showed MINOR EFFECTS on bioavailability, but a 33% increase in Tmax (Time to Maximum Concentration)"


That means it took longer to reach the maximum Riba concentration after taking one dose!!!  Or to make it more clear, a high-fat breakfast SLOWED THE ABSORPTION OF RIBAVIRIN BY 33%!!!!!!!


"A subsequent study by Schering-Plough demonstrated more substantial increases in bioavailability: food increased the AUC (Area Under the Curve) and Cmax (Maximum Concentration) by 70% compared to the FASTING population, and Tmax (Mean Time to Maximum Concentration) which is usually 1.5 hours was more than doubled."


Ribavirin is rapidly absorbed following oral administration. Mean Time to Maximum Concentration after taking a single oral dose is usually 1.5 hours.  So that means that instead of taking 1.5 hours to reach the maximum Riba concentration, it took over 3 hours.  In other words, a high-fat meal increased the maximum concentration of Riba by 70% compared to people who were FASTING but it took TWICE AS LONG to do it.  

In other words, the second study also showed that a high-fat meal slowed the absorption of Riba!!!!  Are you impressed by the 70% concentration?  Why?  It's the same thing that happens after taking multiple doses.
  

"Although both studies consistently showed that food slowed the absorption of ribavirin, the extent to which food affected ribavirin bioavailability differed widely between the studies."

That's right.  One study showed that a high fat meal had no effect on bioavailability.


"It is also UNKNOWN whether any food effect might be altered by the type of meal consumed (eg, high versus low fat), IF A FOOD EFFECT WOULD STILL BE EVIDENT UPON MULTIPLE DOSING OF RIBAVIRIN, and, finally, what clinical implications the food effect might have. It should be noted that in the pivotal Schering-Plough clinical efficacy studies, ribavirin was administered without regard to food. Because of the uncertainty about the effects of food, it may be prudent for patients to TAKE RIBAVIRIN WITH FOOD."

Notice how it DOES NOT say HIGH FAT food.....just food.

  
"The fact that the multiple-dose ribavirin half-life (298 hours) is considerably longer than the single-dose half-life (79 hours) MEANS THAT IT IS NOT POSSIBLE TO PREDICT MULTIPLE-DOSE RIBAVIRIN PHARMACOKINETIC PARAMETERS BASED ON SINGLE-DOSE PARAMETERS.  This has implications for interpretation of food effect pharmacokinetic data."


In other words, the data from the two high fat meal studies is great for those of you who are planning on taking ONLY ONE Ribavirin dose.....LOL

Think about it.  If fat really increased the benefit from Riba, Schering would be selling "Ribavirin ice cream".



Sources:
http://www.medscape.com/viewarticle/416602_2
http://www.drugs.com/pro/ribavirin-capsules.html

[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.

[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

[Kathy73]

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

[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.
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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

[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.  

[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 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]

"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]

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,  

[jmjm530]

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

[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