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PCP PROPHYLAXIS
WITH DRUGS AND HERBS
by Subhuti Dharmananda, Ph.D.,
Institute for Traditional Medicine (ITM)
This version produced March 1996.
http://www.gpo.or.th/
Pneumocystis carinii
is a cyst-forming fungus with characteristics of unrelated protozoal
organisms that causes pneumonia in immune-compromised individuals. It is
believed that virtually everyone is infected by this organism during
early childhood and that it does not cause disease unless it can become
active in the absence of adequate immune responses. The disease it
causes, referred to simply as PCP, occurs mainly in persons treated with
immune-suppressive drugs (e.g. cancer patients and transplant
recipients) and in persons with advanced HIV disease. Until 1989, PCP
was the main cause of death in persons with HIV infection.
At this time, PCP
can usually be prevented and treated successfully with drugs, especially
the combination of TMP/SMX (Bactrim, Septra). Nonetheless, PCP can be
deadly if it is not treated early enough. In an attempt to avoid this
infection, virtually all patients with CD4 count below about 250 are
given the drugs preventatively--those who do not receive the PCP
prophylaxis drugs are usually persons who have avoided HIV-related
testing and persons who have avoided standard medical interventions.
Drug prophylaxis
runs into some problems, mainly intolerance to the drugs by some
patients and failure of the alternative drugs that might be better
tolerated by these patients. The primary intolerance problem is allergy,
usually involving a severe skin rash (continued use can lead to more
serious complications). This has been countered, in some cases, by a
desensitization procedure in which prednisone (which inhibits the
allergy response) is given along with the drugs until the body
acclimates to the continued presence of the drug. While the
immune-inhibiting effects of prednisone have been a concern and it has
been suggested that this approach may increase the incidence of other
opportunistic infections, the most recent study indicates no such
difficulties with this approach. A new study in Los Angeles (ACTG268) is
evaluating whether or not slow introduction of TMP/SMX (with increasing
dosage over a period of several weeks) might not avoid some of the
reactions, thus eliminating the need for prednisone treatment. The
primary failure problem, aside from inconsistency of drug use by some
individuals, is that most of the substitutes for TMP/SMX, such as
Dapsone, Mepron, and pentamidine, that are given to intolerant patients
have a more limited effect and there can be cases of "break through"
PCP, that is, occurrence of the infection despite regular use of the
drugs. Persons who are allergic to TMP/SMX often develop an allergy to
Dapsone over time. It should be pointed out that a benefit of TMP/SMX is
that it is broad-spectrum and, for many individuals, is well tolerated
over a period of years; it can thus effectively inhibit not only
Pneumocystis infection, but other infections, such as Toxoplasmosis and
Aspergillis.
PCP prophylaxis is
the only therapy consistently cited that clearly extends life span of
persons with HIV infection. When TMP/SMX is given in time to prevent a
first bout of PCP and then used consistently by a group of patients,
those individuals will live, on average, about two years longer than
persons who do not use this method of treatment. Aside from the fact
that PCP can be deadly if not treated promptly, when a person
experiences this disorder, there is usually a substantial weight loss
(which is only partly reversed during recovery) and the HIV activity
becomes stimulated (probably as the result of immune activity against
the Pneumocystis and the effects of disease stress on resistance to HIV
effects), leading to some disease progression.
Due to the problems
that some patients experience with the drug therapies, and the great
value in avoiding PCP infection, there has been an effort to find herbs
that can be used along with the less effective drugs or as an
alternative to them. To qualify as a suitable substance, the herb must
have been shown effective against Pneumocystis or related organisms and
it must have been shown to be safe for extended use. There are currently
three major candidates for this purpose.
Garlic is one such
herb which is already recommended for regular ingestion by those with
HIV efforts to find better ways to administer high-potency garlic
extracts are being undertaken. At this time, use of raw garlic (perhaps
in blender drinks as well as in foods) and Kyolic aged liquid garlic
extract (not the dried version) are recommended.
A second example of
a potentially suitable herb therapy for PCP prophylaxis is the
three-herb combination of stemona (root of Stemona japonica), sophora
(root of Sophora flavescens),and phellodendron (bark of Phellodendron
amurense) developed by the current author. These herbs are used in the
treatment of lung diseases, though they have several other
anti-infection applications. In addition to having antiprotozoal,
antibacterial, and antifungal activity, they are also used effectively
in the treatment of human tuberculosis (a type of mycobacterium
infection). These herbs are safe for long term use (according to Chinese
experience in non-HIV patients) and have been utilized, without apparent
adverse reaction, by numerous persons in the U.S. with AIDS who were in
need of additional prophylaxis for PCP or mycobacterium infection (in
the form of MAC). In China, stemona is used as a prophylaxis for
bronchitis. The three-herb combination (combined with three other herbs
to aid digestive functions) has been prepared in tablet form, called
Stemona Tablets, and the suggested dosage is 6 tablets three times
daily.
A third candidate
for therapy is the herb ching-hao (tops of Artemisia annua). This herb
has long been used in China for treatment of infections and for fevers
of unexplained etiology in weakened patients; its main current use is in
treatment of malaria. A laboratory animal study conducted in China
showed that it could inhibit Pneumocystis. A practitioner of Chinese
medicine in New York City (Susan Paul), has been administering this herb
to AIDS patients for the past three years (dosage 6 grams of extract
granules daily) and has claimed that it is safe and apparently of
benefit. Ching-hao has the interesting immunological property of
promoting cell-mediated immune responses and inhibiting antibody-driven
responses (and, for that reason, is used successfully in treating some
autoimmune diseases, such as SLE). It has been proposed that such an
immunological adjustment might be of benefit to persons with HIV
infection, since HIV tends to down-regulate cellular immunity in favor
of humoral immune responses.
It is important to
recognize that the possible herbal therapies for PCP remain unproven at
this time and are not likely to be firmly established as being either
effective or ineffective in the near future. Because of the importance
of PCP prophylaxis to longevity, it is recommended that proven drug
therapies be approached as the first choice, and that herbal therapies
be considered as a back-up in case that the more effective drugs are not
tolerated. It would be a reasonable approach to alternate between the
possible herb therapies to minimize potential problems from extended use
of a single regimen. At this time, it does not appear necessary to use
such herbs along with TMP/SMX for PCP prophylaxis. There may be other
herbs that can aid in tolerance to this drug combination (see the ITM
report on Chinese Herbs that Inhibit Allergy Reactions published
in the Protocol Journal of Botanical Medicine and the International
Journal of Oriental Medicine).
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