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Journal of NeuroVirology

, Volume 25, Issue 4, pp 551–559 | Cite as

The effect of pyridostigmine on small intestinal bacterial overgrowth (SIBO) and plasma inflammatory biomarkers in HIV-associated autonomic neuropathies

  • Jessica Robinson-PappEmail author
  • Alexandra Nmashie
  • Elizabeth Pedowitz
  • Mary Catherine George
  • Sandeep Sharma
  • Jacinta Murray
  • Emma K T Benn
  • Steven A Lawrence
  • Josef Machac
  • Sherif Heiba
  • Seunghee Kim-Schulze
  • Allison Navis
  • Bani Chander Roland
  • Susan Morgello
Article

Abstract

Small intestinal bacterial overgrowth (SIBO) is common among patients with HIV-associated autonomic neuropathies (HIV-AN) and may be associated with increased bacterial translocation and elevated plasma inflammatory biomarkers. Pyridostigmine is an acetylcholinesterase inhibitor which has been used to augment autonomic signaling. We sought preliminary evidence as to whether pyridostigmine could improve proximal gastrointestinal motility, reduce SIBO, reduce plasma sCD14 (a marker of macrophage activation and indirect measure of translocation), and reduce the inflammatory cytokines IL-6 and TNFα in patients with HIV-AN. Fifteen participants with well-controlled HIV, HIV-AN, and SIBO were treated with 8 weeks of pyridostigmine (30 mg PO TID). Glucose breath testing for SIBO, gastric emptying studies (GES) to assess motility, plasma sCD14, IL-6, and TNFα, and gastrointestinal autonomic symptoms were compared before and after treatment. Thirteen participants (87%) experienced an improvement in SIBO following pyridostigmine treatment; with an average improvement of 50% (p = 0.016). There was no change in gastrointestinal motility; however, only two participants met GES criteria for gastroparesis at baseline. TNFα and sCD14 levels declined by 12% (p = 0.004) and 19% (p = 0.015), respectively; there was no significant change in IL-6 or gastrointestinal symptoms. Pyridostigmine may ameliorate SIBO and reduce levels of sCD14 and TNFα in patients with HIV-AN. Larger placebo-controlled studies are needed to definitively delineate how HIV-AN affects gastrointestinal motility, SIBO, and systemic inflammation in HIV, and whether treatment improves clinical outcomes.

Keywords

HIV Autonomic neuropathy Pyridostigmine Dysmotility SIBO Inflammation 

Notes

Funding information

This study was funded by the National Institutes of Health (PI Robinson-Papp, R21DK105917: “Autonomic neuropathy, gastrointestinal motility, and inflammation in HIV”). Additional laboratory support was provided by U24MH100931: “The Manhattan HIV Brain Bank.”

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Copyright information

© Journal of NeuroVirology, Inc. 2019

Authors and Affiliations

  • Jessica Robinson-Papp
    • 1
    Email author
  • Alexandra Nmashie
    • 1
  • Elizabeth Pedowitz
    • 1
  • Mary Catherine George
    • 1
  • Sandeep Sharma
    • 1
    • 2
  • Jacinta Murray
    • 1
  • Emma K T Benn
    • 2
  • Steven A Lawrence
    • 2
    • 3
  • Josef Machac
    • 4
  • Sherif Heiba
    • 4
  • Seunghee Kim-Schulze
    • 5
  • Allison Navis
    • 1
  • Bani Chander Roland
    • 6
  • Susan Morgello
    • 1
  1. 1.Department NeurologyIcahn School of Medicine at Mount SinaiNew YorkUSA
  2. 2.Center for Biostatistics and Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkUSA
  3. 3.School of Science, Health & TechnologyThe City University of New York Medgar Evers CollegeNew YorkUSA
  4. 4.Department of Radiology, Division of Nuclear MedicineIcahn School of Medicine at Mount SinaiNew YorkUSA
  5. 5.Human Immune Monitoring CenterIcahn School of Medicine at Mount SinaiNew YorkUSA
  6. 6.Division of Gastroenterology, Department of MedicineNorthwell HealthNew YorkUSA

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