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233616 tn?1312790796

Ribavirin absorption-fats and PURINEs?!?!?!?

Been working on my ideal strategy for next round of tx. and came across this little study of how high purine foods lower Riba absorption.
Since all we've ever discussed in here is how FAT helps riba to absorb,
I thought knowing what might hinder it's absorption was worth knowing also.

Ribavirin is found to be absorbed in the intestine through the human concentrative nucleoside transporter 2 (hCNT2). Cellular uptake of ribavirin was strongly inhibited by purine nucleoside in an in vitro study. This study aims to examine the effects of dietary purine on the pharmacokinetics of orally administered ribavirin in vivo. Twenty healthy participants were enrolled in a randomized, 2-period crossover study. Participants were administered a single 600-mg oral dose of ribavirin after either a high-purine meal or a low-purine meal. Serial blood samples were collected predose and over 144 hours after dosing. Ribavirin concentrations were measured by liquid chromatography/tandem mass spectrometry. In comparison with corresponding plasma values of ribavirin following a high-purine meal, Cmax, AUC0-144 and AUC0-∞ of ribavirin following a low-purine meal were 136% (90% confidence internal [CI]: 120%-155%), 134% (90% CI: 118%-153%), and 139% (90% CI: 120%-159%), respectively. This study indicates that dietary purines have an effect on ribavirin absorption. Dosage regimens of ribavirin might need to be adjusted according to the purine content of the meal.

SO I guess we can kiss our meat, fish and legumes goodbye....or at the very least limit them, as HR once suggested purely for liver health.

Now those treating have extra incentive to limit thier intake, or to at least plan their high protein meal to be at a different time than when they ingest their Ribavirin.

Discussion is welcomed.

125 Responses
233616 tn?1312790796
There's far more to this than we might think.

Another good idea would be to double check your vitamins, especially you body builders.

Make sure you are not taking supplements containing ISONINE, which inhibits riba absorption as well.

Meats, and brewer's yeast also are high in isonine.

979080 tn?1323437239
thanks merrybe , very interesting.
Not being able to test Riba  serum concentrations I have been using my HgB as an
indicator for absorption.
Avatar universal
"SO I guess we can kiss our meat, fish and legumes goodbye....or at the very least limit them, as HR once suggested purely for liver health."

Or you could take a higher dosage of ribavirin, it seems to have worked for several others after not having success the first time.

Good Luck- Dave
233616 tn?1312790796
good point Dave, and good idea Bali (although marrow's respond differently so its not a perfect correlation and as the body wears down from the tx I wouldn't count on that being a good indicator. If the marrow gets fried, like from Epo it sometimes will, then the HGB level wouldn't be telling you much at all as regards Riba levels.)

I'm thinking that sice Riba is the most problematic drug, it doesn't absorb well at all, that extra care should be excersised to get it into the blood.

The sooner the riba levels get to optimum, the better the chance of SVR, which is why they are working on several drugs now, to help the riba get into the system.

Since those drugs are still a couple years from approval, I think the best approach would be to take the riba in a meal or snack that does not include prines or isonine, but does include fat....and yes, upping the dose would help, the only problem is very few docs will give you that option since going beyond SOC means they would be liable should your kidneys give out.

I'm recalling Karen Lindahl's study, where higher Riba levels all SVR'd, but 20% had kidney issues or failures at the higher doseage levels.
Since plasma is not tested in the USA for riba levels, (boy would that help), no docs are tailoring the meds to the patient's life style or eating habits. Were they to test, they could then up the dose for just the patients that need that.
Again, I think they should, but will they ever...don't hold your breath.

Isomine has been shown to inhibit Riba absorption in the intestines as well as purines,
but I'm thinking that most docs will not inform patients of any of this either.
Just like they don't inform as to Iron overload, or the other stuff.

My clinic has a 2 hr class for newbies, and it included none of this info.
Dietary adjuncts are just not thought to be very important, evidently.

In my case, the moment I found out about fat adding, and too much roughage harming Riba absorption I altered my diet, and went UND within 2 weeks of doing so, but prior to that I had not been able to get a good log drop, and had in fact had my VL rise again at week 16.  

Ergo diet really does effect outcome, much more than medicine is letting on.

Ideally, we will get an approval of a good drug to get Riba to optimal levels in days, not weeks or months, but until then there are some things the educated patient can do to help them succeed in tx.

I just hope folks will begin to share their experience with their doctors so that the good research that has been done, even though limited, might begin to be taken seriously.

Avatar universal
"SO I guess we can kiss our meat, fish and legumes goodbye....or at the very least limit them, as HR once suggested purely for liver health."

I read your post yesterday morning and didn't have time to respond until now.  First off, I am relatively new to the battle - shot #9 of 24 yesterday, on Lambda INF and Riba.

I read your caution about limiting high purine foods.  Beans are a significant part of my heart healthy diet (HDL of 99) and I thought this is awful...  This morning in rereading your post I had to wonder what the cited study considered to be "a high purine meal."  After finding this list of foods and purine amounts, I not only feel okay with eating beans, I was also surprised to see that there's even some beef in the "low" purine list:  


Other confusing issues:  I had read on this board to increase fat consumption and started out trying that.  Was getting nauseas and the study RN said the Riba dose had already been determined to be consumed with normal healthy eating.  Okay, I'll let that concern go.  

I'm also a bit concerned that I am on iron per doctors orders - low ferritin level before starting - and all of the cautionary posts that I've read about iron inhibiting SVR outcome and being toxic to the liver.  So, I stopped my iron for a period and felt better that my hgb had dropped on next test.  But, I could feel loss of energy and restarted fe.  Hgb holding as of yesterday's blood work.

Oh, and fiber.  I take psyllium and gluccomannan.  Along with a number of supplements - all of which were given the okay by the sponsoring drug company.  

I guess that part of my post is a rant but this gets so damnable frustrating that I would love to see a list put together of important points that might not be covered by your doctor.  As it is, I'll be having my primary doing a number of blood tests when I see him next week, just so I can try to keep an eye out for myself.

And so, that's my addition to the discussion.
233616 tn?1312790796
I agree, it gets confusing.

The best we can hope for it to put into practice the things that have been onserved however, as until they bust the riba absoption riddle it is the most risky item in the SOC.
The longer it takes to get to steady state, the more chance of mutation and resistant strains.

Some folks are even predosing their riba to compensate, some studies include predose arms, so its really an importent issue.

THANK YOU so much for the purine food list, I looked that night before starting the thread and couldn't find a good one, so I want to thank you for that.

You'll notice BREWERS YEAST is very high.

That means to everyone this:  WE SHOULD NOT TAKE A MULTIVITAMIN at the same TIME we take our riba.

Basically, inosine follows the same sort of numbers as the purine list, meaning you can avaoid high inosine by simply avoiding high purine foods.
The EXCEPTION to this would be those who are taking MUSCLE BUILDING supplements or body building drinks. Many of them contain inosine.
It is expensive so they don't all contain it...but reading labels is a good thing here.

Here's a link by the way, showing how inosine stops dead the riba absorption in the bowel tissue....it's in the conclusion and you have to ZOOM IN to be able to read it.


Susan, I appreciate your concern...I'm bummed I had to change my diet so much to accomodate this drug...but as I said, before I did the alterations I was not even going down in VL....and that's probably why, I probably was knocking out the riba by including the proteins in every meal.
I had included the proteins because a doctor said eating protein in small quantity several times a day was better for a sick liver...which it IS.
The only problem was, it turns out that it is not going to allow for optimum riba absorption.

Karen Lindhal's study showed that everyone with high plasma riba SVR'd, so to me its important for treater to know how to keep that drug absorbing.

233616 tn?1312790796
sorry for my mispelling...my bad....inosine   I no seein"...if they give out awards in medhelp I'll get the worst speller one hands down!!

maybe I'll stop transposing when my brain fog lifts...in the after life.
233616 tn?1312790796
I finally found a list of grains and their purine content.

oatmeal = 92

wheat and barley = 51

I guess this means I'd be better off to have cracked wheat for my breakfast with riba that to choose oatmeal.
233616 tn?1312790796
please take note that inosine almost completely interfered with riba absorption in the presence of NA+ gradient in the link I gave.

that's med speak for if you salt your meat or eggs, it inhibits the riba more.
So basically the higher the complete protein, the higher the salt with it, the less riba will be absorbed.

Good information....can I get an amen??
Avatar universal
First let me say that I think it was a tough break for you to tx as long as you did and then relapse.  Maybe all of your research will not only help get you through and maintain SVR next go round but some of your research may prove instrumental in a better approach to diet during tx.  

I do wonder though just how many variables there are to the riba absorption.  For example, I take phosphatidylserine (PS) which has been found to make the cell membranes more "porous" and better able to pump nutrients in and waste out.  (From there it goes on to having other beneficial effects.)   Diet and nutrition often spark such hot debate that I imagine this may be one reason the researchers aren't focusing on it.  From what I've read here, many on SOC are doing their best when they get any food in - let alone recommended foods.

I'm a few weeks from my 12 week bloods after which point my study is no longer blinded.  I am curious to see the outcome of course - but mostly because of all the fiber, supplements, and a diet that is limited to avoiding trans fats, HFCS, white foods, and foods with a label.  My roll of the dice :).
979080 tn?1323437239
The thing I have been wondering is why only take Riba twice a day instead for example
three times a day. If we are going for even plasma concentration isn`t three x 400
thruout the day better than two times 600 when total dose is 1200 ?

I bet the only reason why we have the two time dosing is because more people
were adhering to taking their meds on time in the original trials.

Anyway if you can take enough Riba to max out your HgB than absorption is no longer
an issue since if you get any more into your systems you will become too anemic
requiring dose reduction or EPO.

Still waiting to see someone to come up with a good thought out meal plan for tx.

233616 tn?1312790796
yes you are right its darn hard to eat, and I hate to add to that EXCEPT that the more we learn the more will SVR. It made no sense to me that my VL went up 200,000 went I was So compliant, but when I changed my diet it went to UND, and even doctor are telling patients now to include fats with the riba, so at least they've come around on that score.

I don't know Bali, I think given the facts I'd stick with something lower protein for breakfast, a bowl of wheat cereal would be low fiber, of some sort would be better than oats. I like the idea of the bulgar or cream of wheat because you can add fat to that, and add some agave or stevia, or just cook some raisins in it for sweetness...that is sort of a comfort food, and I found that warm cereal was the easiest thing for me to tolerate, kept my stomach calmer.

Then at lunchtime get at least 3 ounces of protein, and lots of veggies and some fruit,

At dinner, I'd again go light on proteins, and light on fibers, cream soups, things like pastas, things like these can accomodate fat again and help the riba absorb. A little protein in a soup or pasta dish is ok but keep it to an ounce or less if you can manage.

then towards bedtime have a little protein/fiber snack.

This way you are getting your protein and fiber, but not at the time you take your ria, then you stick with things that help rather than hinder absorption.

BTW, a snack at night tend to lower morning blood sugars, so this type diet will help keep the INF from being canceled out.

I'll try to work out a more comprehensive plan when I get time.
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