Licking Lipo : The Med Connection - by Derek Thaczuk

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Back to home » HIV 101 » POZ Focus » Licking Lipo

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Licking Lipo

Body Language

The Med Connection

Ready, Set, Switch?

Lipo Fix-Its


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The Med Connection

by Derek Thaczuk

What connects your life, your HIV treatment and lipodystrophy? Derek Thaczuk fingers the most likely culprits in your bathroom cabinet and offers some clues on how to thin the odds

What causes the thinning faces, bulging bodies and climbing cholesterol levels associated with some HIV medication? More to the point, how do we stop it? Researchers are delving into lipo’s metabolic mysteries—there’s even an International Workshop on Adverse Drug Reactions and Lipodystrophy that meets yearly on the subject—and the findings are sometimes surprising.

For instance: It turns out lipo’s fat gain and loss are actually two distinct phenomena (at least in men); earlier theories charted “migrations” of fat around the body. Also: Drugs are not the only culprit. Study after study has pegged aging as one of the biggest lipo risk factors of all. HIV meds play a central role, though, and (unlike age!) they’re adjustable—for most of us.

So here’s the latest on which treatment tweaks may minimize your lipo risk and fight its effects.

Fat Loss
Look out for Zerit, AZT—and timing

What it is:
Lipoatrophy involves any combination of the following: gaunt faces, thin and veiny arms and legs and flat butts.

What causes it:
Studies have repeatedly pegged Zerit (d4T) as the med most likely to thin the limbs and hollow the cheeks. In second place is the other so-called thymidine analog—that’s AZT to you and me. In addition to the myriad other risks  associated with low CD4 counts, reviews of studies have pegged counts below 100 and advanced HIV disease as definite risk factors for lipoatrophy. Finally, the amount of time spent on therapy—especially Zerit, but to some extent protease inhibitors (PIs) as well—seems to matter, too.

What you can do:
Fortunately, “we know a lot more about the causes of lipoatrophy than we did a few years ago,” says Paul E. Sax, MD, clinical director of the HIV program at Brigham and Women’s Hospital in Boston. “With that knowledge, we’re prescribing regimens that are much less likely to cause it.”

Better to go with Ziagen (abacavir), Viread (tenofovir), Emtriva (FTC) or Epivir (3TC) as initial choices, says Dr. Sax. If you’re already experiencing lipo loss, treatment tweaking can help. The new Randomised Abacavir Viread Evaluation (RAVE) study, presented at the 12th annual Conference on Retroviruses and Opportunistic Infections (CROI) in February 2005, showed that patients gained limb fat when they switched from AZT or Zerit to Ziagen or Viread. In another study, Gilead’s 934, patients taking a Combivir and Sustiva combo had lower limb fat than patients taking Sustiva with Viread and Emtriva (Truvada).
The findings are less certain about when to get started on HAART given that both waiting too long and being on it too long are associated with fat loss. All the more reason to work with your doctor on picking that “perfect place to start.”

Blood Problems
The cholesterol and insulin factors 

What it is:
Some treatment-related side effects don’t show up in your mirror at all. “Metabolic abnormalities” is the blanket term for accumulating extra fats in your blood, including LDL (“bad”) cholesterol; dropping HDL (“good”) cholesterol; and increasing blood sugar and insulin resistance. These are longer-term, “stealth” problems, measurable only by blood tests until they lead to trouble like heart disease or diabetes later on.

What causes it:
The federal treatment guidelines from the Department of Health and Human Services (DHHS)—the American bible of antiretroviral usage—paints most protease inhibitors with the same brush, blaming “all PIs except Reyataz [atazanavir].” In addition, the guidelines zero in on nuke Zerit and, “to a lesser extent,” non-nuke Sustiva (efavirenz) as likely to increase blood fats.

What you can do:
Some PIs are believed to be worse than others, so it’s all about picking your PIs with precision. Though opinions differ, Toronto’s Alex Klein, MD, ranks them this way: “Crixivan [indinavir] most definitely boosts lipid levels. So, to a lesser extent, do Norvir [ritonavir] and Kaletra [ritonavir + lopinavir]. The least worrisome is Reyataz, which is known for its lipid-friendly profile.”

Certainly, Reyataz has staked a reputation as the least likely to mess with lipid levels–a plus that (as always) has to be measured against all the other pros and cons. So it boils down to realizing that taking a PI can be problematic, but is not necessarily synonymous with elevated lipid levels. “Plenty of people on PIs do just fine, so it isn’t automatically going to happen,” says Judith Currier, MD, professor of medicine at UCLA and codirector of its CARE Center. “You have to look at each one individually.”

Lipo Lumps
Age matters—but what else?

What it is:
Lipo-related fat gain is a different beast than plain old obesity or your average beer belly. It shows up as hard, dense fat deep in the belly and breasts, or on the back of the neck and shoulders (“buffalo hump”).

What causes it:
Fat accumulation is the most misunderstood piece of the lipo puzzle. Recent studies have even questioned whether meds are a cause at all: Age seems to be the leading risk for bulging middles. In fact, in 2004, the large-scale MACS (Multicenter AIDS Cohort Study) found that HIV positive people didn’t show significantly more fat buildup than people who are HIV negative.

Dr. Sax begs to differ. “That’s contrary to what we see with our own eyes in our patients,” he says. “Truncal [breast and belly] fat accumulation is not unheard of in the aging HIV negative population, but the extreme ‘buffalo hump’ of some people with HIV is certainly not normal.”

At least one drug seemingly can’t be blamed. In the 2005 Fat Redistribution and Metabolic Change study (FRAM), Viramune (nevirapine) was the only HIV med linked with lower “visceral adipose” fat—the type of dense belly fat  characteristic of lipodystrophy.

Researchers will be depending on future studies  to make clearer distinctions. But meanwhile, it’s worth noting that if blood tests indicate that your cholesterol is putting you into the heart attack zone or that your insulin sensitivity has dropped down to near-diabetes levels, you may be at greater risk for HIV-related fat gain.

HIV med use in general correlates with fat gain, and the longer you’re on treatment, the more likely you’ll get hit.

What you can do:
OK, so age is a factor. But “be younger” isn’t helpful advice. Still, most docs endorse good eating and moderate exercise as a defense against lipo. “There’s no question about the benefits of exercise and a healthy diet,” says Judith Currier, MD. “No matter how big a part meds may play, your body composition depends on genetics, diet and exercise, too.”





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