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Nausea and VomitingThe Unforgiving Side Effects

by Richard S. Ferri, Ph.D., ANP, ACRN, FAAN

Nausea and vomiting are frequent and debilitating side effects of antiretroviral therapy and HIV disease. They can not only impact quality of life but can also affect the ability to adhere to the desired medication regime. Patients may often complaint that they feel sick to their stomach and are unable eat or take medication.

While nausea and vomiting frequently occur together, they also are distinctly separate clinical entities. Nausea is defined as a subjective feeling of the need to vomit that typically occurs in the throat or epigastrium; vomiting is the forceful expulsion of gastric contents. Both of these symptoms can lead to nutritional impairment, dehydration, and electrolyte imbalance.

One of the major causes of nausea and vomiting in the HAART era are the antiretrovirals themselves. In fact, the most common adverse events that causes persons living with HIV to decrease their dosing of antiretrovirals or to discontinue them altogether are the gastrointestinal side effects of such drugs.
Nausea, which usually precedes vomiting, is associated with diminished stomach, duodenum, and small intestine motility. There are two distinct medullary centers in the brain that trigger vomiting. They are the vomiting center and the chemoreceptor trigger zone (CTZ). Vomiting may occur by stimulation of involuntary visceral and somatic events.

Other causes of nausea and vomiting include viral, bacterial, and parasitic infections of the gastrointestinal tract. In addition, food intolerance and medication side effects are often culprits. Anticipatory nausea is a learned behavior that can be stimulated by association with expected unpleasant events.

Not being able to take antiretroviral therapy as a result of being nauseous can lead to virologic failure and drug resistance. In the age of HAART, the treatment of nausea is no longer just a symptom-management issue but a treatment-adherence mandate. It is unreasonable to think that anyone is going to be able to take any medication on a consistent basis if they are nauseous.

Prevention is key in the management of nausea and vomiting. Clinicians should review the possibility of such side effects occurring with the start of a new antiretroviral regime or a change in the treatment plan. It is necessary to guide patients through these events and to provide proactive interventions. These interventions include patient education about the need to take antiemetic medications as prescribed, the avoidance of offending foods, and the need to decrease stress and reduce noxious stimuli.

Some nonpharmacological interventions that may help control nausea and vomiting include:

" Eat small meals very 2 to 3 hours instead of three large meals a day
" Eat slowly and chew food thoroughly
" Eat food that is cold or lukewarm to lessen any offending smells
" Eat crackers or dry toast in the morning
" Sipping flat beverages such as sports drinks or weak tea through a straw

Often is necessary to provide pharmacological interventions to help control nausea and vomiting. Many antiemetics work by blocking stimulation that may trigger the CTZ or the central nervous system. Others help by delaying gastric emptying or decreasing GI motility.

Relief of nausea and vomiting is essential to high quality care and treatment adherence in the age of HAART.

Dr. Ferri received his Masters of Science in PrimaryHealth Care Nursing, Adult Nurse Practitioner, from Simmons College and Ph.D. in Adult Education and Development from Columbia Pacific University, and a master of science in adult educationand human resource development from Fordham University in New York. He is certified as an AIDS Certified Registered Nurse (ACRN) and has served the elected positions of president and national director for the Association of Nurses in AIDS Care (ANAC) the HIV/AIDS Nursing Certification Board (HANCB) from 19992000. He currently practices in an independent consulting firm in the areas of HIV/STD clinical management and lends his expertise to continuing medical and nursing education program development, editing, writing, and scripting for multi disciplinary audiences, workshops/seminars in HIV/STD management, mens health issues, gay and lesbian issues (domestic violence, breast cancer, prostate disease), and adolescent health care.

Dr. Ferri has co-authored eight textbooks and written more than 40 articles in such journals as
RN, Nursing Spectrum, The American Journal of Nursing, The Journal of the Association of Nurses in AIDS Care, and Advance for Nurse Practitioners. He is on the editorial board/review panel of several professional journals, he has presented at more than 35 national symposia and workshops. Dr. Ferri is a Distinguished Lecturer in HIV/AIDS Nursing for the ANAC. He is a clinical expert in HIV nursing for the International Council of Nurses, and is a Fellow of the American Academy of Nursing. In November of 2000, he was awarded the ANAC Lifetime achievement award for this contributions to AIDS care.

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