Interventions for managing antiretroviral therapy-associated lipoatrophy

Natural Course of Nonalcoholic Fatty Liver Disease and Type 2 Diabetes in Patients With Human Immunodeficiency Virus With and Without Combination Antiretroviral Therapy-associated Lipodystrophy: A 16-Year Follow-up Study

BACKGROUND

Abnormal glucose metabolism and nonalcoholic fatty liver disease (NAFLD) are common in patients with human immunodeficiency virus (HIV+ patients), but longitudinal data are lacking. We determined the natural course of NAFLD (liver fat [LFAT]) and type 2 diabetes mellitus (T2DM) in HIV+ patients with and without lipodystrophy (LD+ and LD-, respectively) during a 16-year longitudinal study.

METHODS

LFAT (by proton magnetic resonance spectroscopy) and clinical characteristics were measured in 41 HIV+ patients at baseline and after 16 years. Liver fibrosis was estimated by measuring liver stiffness using transient elastography (TE) and magnetic resonance elastography (MRE) at 16 years. We also longitudinally studied 28 healthy subjects.

RESULTS

During follow-up, the HIV+ patients gained more body fat (8.6% ± 0.7%) than the control patients (4.5% ± 0.6%, P < .001). Features of insulin resistance increased significantly in the HIV+ patients but not the control patients. A significant proportion (20%, P < .01 vs 0% at baseline) of the HIV+ but none of the control patients developed T2DM. LFAT was significantly higher at baseline in the LD+ (4.3 [1.9-11.8]) than the LD- (1.0 [0.5-1.5]; P < .001) HIV+ patients. LFAT remained stable during follow-up in all groups. At follow-up, liver stiffness measured with TE was similar among all HIV, LD+, LD-, and control patients and between the LD+ and LD- patients measured with MRE. Advanced fibrosis by MRE was observed in 3 of LD+ and none of LD- patients.

CONCLUSIONS

During 16 years of follow-up, progression of NAFLD is rare compared to development of T2DM in HIV+ patients.

HIV-associated lipodystrophy: a review from a Brazilian perspective

The prognosis of human immunodeficiency virus (HIV)-infected individuals has dramatically improved worldwide since the introduction of highly antiretroviral therapy. Nevertheless, along with the decrease in mortality, several body modifications not initially related to HIV infection have been reported. Disorders in lipid and glucose metabolism, accompanied by body shape abnormalities and alterations in fat distribution, began to be described. A syndrome, named "HIV-associated lipodystrophy syndrome", was coined to classify these clinical spectrum aspects. This syndrome involves not only metabolic alterations but also fat redistribution, with lipoatrophy due to subcutaneous fat loss (predominantly in the face and lower limbs) and lipohypertrophy related to central fat gain. These changes in body shape are very important to be recognized, as they are associated with worse morbidity and mortality. Self-esteem difficulties related to body alterations might lead to treatment failures due to medication adherence problems. Moreover, these alterations have been associated with an increased risk of cardiovascular events. Therefore, it is extremely important to identify this syndrome early in order to provide an even better quality of life for this population, as the clinical approach is not easy. Treatment change, medications to treat dyslipidemia, and surgical intervention are instruments to be used to try to correct these abnormalities. The aim of this study is to review clinical presentation, diagnosis, and management of body shape and metabolic complications of HIV infection from a Brazilian perspective, a medium income country with a large number of patients on antiretroviral therapy.

Treatment of facial lipoatrophy with polymethylmethacrylate among patients with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS): impact on the quality of life

BACKGROUND

The lipodystrophy syndrome is characterized by selective loss of subcutaneous fat on the face and extremities (lipoatrophy) and/or accumulation of fat around the neck, abdomen, and thorax (lipohypertrophy). The aim of this study has been to assess the impact of polymethylmethacrylate facial treatment on quality of life, self-perceived facial image, and the severity of depressive symptoms in patients living with HIV/AIDS.

METHODS

A non-randomized before and after interventional study was developed. Fifty-one patients underwent facial filling. The self-perceived quality of life, facial image, and degree of depressive symptoms were measured by the Short-Form 36 and HIV/AIDS--Targeted quality of life questionnaires, by a visual analogue scale and by the Beck depression inventory, respectively, before and three months after treatment.

RESULTS

Six of the eight domains of Short-Form 36 and eight of the nine dimensions of the HIV/AIDS--Targeted quality of life questionnaires, together with the visual analogue scale and by the Beck depression inventory scores, revealed a statistically significant improvement. The only adverse effects registered were edema and ecchymosis.

CONCLUSION

The treatment of facial lipoatrophy improved the self-perceived quality of life and facial image as well as any depressive symptoms among patients with HIV/AIDS.

Four-year follow-up of polyalkylimide gel use for the treatment of HIV-associated lipoatrophy

PURPOSE

To evaluate polyalkylamide gel (PAIG) use in treating HIV-associated facial lipoatrophy (FLA) 4 years after its injection in an open-label, randomized controlled trial (RCT).

METHODS

Five patients were treated with PAIG in a pilot study, and 31 patients were subsequently enrolled in the RCT of immediate or delayed (12 weeks later) PAIG injections. Endpoints included proportion of participants with complications; changes in FLA severity score (FLSS); and quality of life (QoL), depression, anxiety, and satisfaction scores. Infections were classified as "confirmed" if purulent material was extracted and/or an organism cultured. Infections were classified as "possible" if only clinical signs were present without purulent discharge or microbiologic confirmation.

RESULTS

Year 4 results were available for 5 pilot and 27 full-scale study participants. Delayed complications included 5 confirmed infections (15.6%), 3 possible infections (9.4%), nodules (25%), and bleeding (3%). No significant changes were observed between years 2 to 4 in patient-graded FLSS, QoL, depression, and anxiety scores. Whereas 94% of participants were satisfied with their overall treatment, only 69% were satisfied with PAIG treatment specifically.

CONCLUSION

Even though PAIG treatment was associated with delayed complications including high rates of infection and nodules, most patients were satisfied with the treatment.

Cost of surgical intervention for reconstructive therapy of HIV-associated facial lipoatrophy

This study aims to assess direct cost of reconstructive interventions with facial fillers for treatment of HIV (human immunodeficiency virus)-associated facial lipoatrophy (FLA). Evaluation was performed on data from patients enrolled in one arm of a comparative study of immediate versus delayed reconstructive treatment of facial lipoatrophy. Median costs were standardized for efficacy, estimated using data reported by physicians and patient reported outcomes. The variations of the results were evaluated with a sensitivity analysis. Evaluation was performed on 66 patients characterized by significant differences in terms of severity of FLA. Total cost resulted of €140,416.15, with a median cost per patient of €2126.04 (interquartile range [IQR]: 1599-2822). Taking into consideration severity of disease, median costs were €1641.67 (IQR: 1326.67-2126.04) and 2557.12 (IQR: 1939.34-2872.04) (P = 0.0) respectively for patients with low and high severity scores at baseline. Significant differences in term of cost-effectiveness ratios were also found between patients with different severity of FLA, and sensitivity analysis showed that these ratios increase with higher severity scores at baseline and vary widely depending on the costs of filler. Although these results cannot be considered representative because of important limitations, the present study suggests the severity of disease as an important determinant of costs.

Metabolic complications associated with antiretroviral therapy in HIV-infected and HIV-exposed uninfected paediatric patients

IMPORTANCE OF THE FIELD

HIV-infection has become a chronic disease in paediatric patients with the potential for long-term survival and exposure to antiretroviral (ARV) therapies for 2 decades longer than HIV-infected adults. On the other hand, the administration of ARV to HIV-infected pregnant women has greatly increased both treatment of HIV infection and prevention of perinatal HIV transmission. Therefore, researches aiming to evaluate the safety of ARV therapies in HIV-infected children as well as in HIV-uninfected infants born to HIV-infected mothers are emerging as a new challenge and urgent priority.

AREAS COVERED IN THIS REVIEW

The purpose of this review is to describe some of the more concerning metabolic complications associated with ARV in paediatric population: hyperlactataemia (HLA) syndromes, body shape abnormalities, disorders of glucose homeostasis and dyslipidaemia in HIV-infected children and adolescents. Frequency, risk factors, clinical findings, prevention and intervention strategies of the previously described abnormalities are discussed in depth.

WHAT THE READER WILL GAIN

This review covers our current understanding of HLA syndromes in ARV-exposed uninfected infants born to HIV-infected mothers.

TAKE HOME MESSAGE

Prevention of these metabolic complications should assume prominence and future researches should address several of the existing treatment gaps.

Long-term efficacy and safety of polyalkylimide gel for the treatment of HIV-associated lipoatrophy

The long-term safety and efficacy of products used in the correction of HIV-associated facial lipoatrophy (FLA) are largely unknown. The purpose of this study was to describe the long-term efficacy and safety of polyalkylimide gel (PAIG) in the treatment of HIV-associated FLA. In this open-label, randomized, single-center study, 31 HIV-positive individuals (median age 48 years (interquartile ranges (IQR) 45, 55, 97% male) with FLA were randomized to immediate (week 0 and six) or delayed (week 12 and 18) PAIG injections. Week 96 endpoints included change in FLA severity scores (FLSS) (five-point scale), proportion of patients with adverse events, and changes in quality of life, depression and anxiety using validated surveys. Results at week 96 were available for 28 patients. Adverse events, including swelling, redness, bruising and pain, were mild, and resolved after a median of three days following the injection. At week 96, median changes in physician and patient FLSS scores were -2 (IQR -3, -1; p<0.001 vs. baseline) and -2 (IQR -2, -1; p<0.001 vs. baseline), respectively. Physician and patient FLSS scores were not significantly different between the groups at week 96. Significant improvements in patient's anxiety (p<0.001), depression (p<0.001) and mental health (p=0.01) were observed from baseline to week 96. In conclusion, treatment with PAIG was associated with sustained improvements in both the physical and psychological components of FLA through 96 weeks of follow-up.

Prevalence of and clinical factors associated with lipoatrophy in HIV-infected Koreans receiving highly active antiretroviral therapy

Lipoatrophy is the long-term adverse effects developed in human immunodeficiency virus (HIV)-1-infected subjects receiving highly active antiretroviral therapy (HAART). This cross-sectional study aimed to evaluate the prevalence of and clinical factors associated with lipoatrophy in HIV-infected Koreans receiving HAART for more than 6 months. Lipoatrophy was diagnosed by concordance between physical examination and history taking performed by a single physician. Various covariates were examined, including diabetes mellitus (DM), lipid profiles after HAART, and HAART regimen and duration. Among total 144 patients (6 females and 138 males), 35 patients (24.3%) were diagnosed with lipoatrophy. The prevalence of lipoatrophy was significantly higher in females than that in males [83.3% (5/6) vs. 21.7% (30/138), p = 0.010] and higher in patients with DM than patients without DM [66.7% (4/6 DM) vs. 22.5% (31/138 non-DM), p = 0.030], or in patients with high total cholesterol levels than patients with low total cholesterol levels [31.9% (23/72 patients with high cholesterol) vs. 16.7% (12/72 patients with low cholesterol), p = 0.035]. Moreover, patients with stavudine treatment history (> 12 months) had a higher prevalence of lipoatrophy than patients who never received stavudine [50.0% (15/30) vs. 16.5% (17/103), p < 0.001]. In the multivariate logistic analysis, stavudine treatment for > 12 months (OR, 3.67; p = 0.011) and being female (OR, 24.93; p = 0.009) are independently associated with lipoatrophy. In conclusion, the prevalence of lipoatrophy in HIV-infected Koreans receiving HAART is not uncommon. Limited use of stavudine and regular monitoring are warranted to reduce lipoatrophy.

Immediate versus delayed surgical intervention for reconstructive therapy of HIV-associated facial lipoatrophy: a randomized open-label study

We assessed the safety and efficacy of reconstructive therapy with facial fillers for the treatment of HIV-associated facial lipoatrophy (FLA) through a randomized, controlled, open-label single-center study. A total of 134 HIV-infected patients with severe FLA were randomly assigned to receive immediate (67 patients) or delayed (67 patients) facial injections of poly-l-lactic acid (PLA) or polyacrylamide gel (PAIG). Outcome measures included changes in physician and patient FLA severity scale, adverse events, and changes in health-related quality of life (HRQoL) and anxiety using validated measures. The mean average study follow-up was 27 weeks for the immediate and 25 weeks for the delayed subjects. Adverse events were mild and resolved after a mean of 4 days. Compared to patients randomized to the delayed treatment group, patients assigned to the immediate treatment group had significantly lower physician-rated (0.0 versus -3.0; p < 0.0001) and patient-rated (0.1 versus -1.8; p < 0.0001) FLA severity scores. By contrast, measures exploring HRQoL and anxiety did not show any significant difference between patients randomized to the immediate and deferred groups. Reconstructive therapy with facial fillers was effective and safe and led to significant improvements in FLA severity. However, no significant gains in HRQoL, relational and psychological consequences of body changes, and anxiety-related concerns were observed. Studies should be performed to identify patients who could maximally benefit from filling interventions for FLA.

The effects of Thiazolidinediones on metabolic complications and Lipodystrophy in HIV-infected patients

Highly active antiretroviral therapy (HAART)-associated metabolic complications include lipoatrophy (loss of subcutaneous adipose tissue (SAT)) and insulin resistance. Thiazolidinediones are insulin-sensitizing antidiabetic agents which-as an untoward side effect in obese diabetic patients-increase SAT. Furthermore, troglitazone has improved lipoatrophy and glycemic control in non-HIV patients with various forms of lipodystrophy. These data have led to 14 clinical trials to examine whether thiazolidinediones could be useful in the treatment of HAART-associated metabolic complications. The results of these studies indicate very modest, if any, effect on lipoatrophic SAT, probably due to ongoing HAART negating the beneficial effect. The benefit might be more prominent in patients not taking thymidine analoges. Despite the poor effect on lipoatrophy, thiazolidin-ediones improved insulin sensitivity. However, especially rosiglitazone induced harmful effects on blood lipids. Current data do not provide evidence for the use of thiazolidinediones in the treatment of HAART-associated lipoatrophy, but treatment of lipoatrophy-associated diabetes may be warranted. The role of thiazolidinediones for novel indications, such as hepatosteatosis, should be studied in these patients.

Treatment of altered body composition in HIV-associated lipodystrophy: comparison of rosiglitazone, pravastatin, and recombinant human growth hormone

PURPOSE

Treatment options for HIV-associated lipodystrophy syndrome (HALS) remain limited. The objective of this randomized open-label study was to compare three emerging therapies, rosiglitazone, pravastatin, and growth hormone alone and together, in men and women with HALS.

METHOD

Sixty-four subjects received daily rosiglitazone (4 mg, n = 14), pravastatin (40 mg, n = 11), or rosiglitazone plus pravastatin (n = 13) for 48 weeks or recombinant human growth hormone (rhGH; Serostim 2 mg, 12 weeks, n = 13) alone or combined with rosiglitazone (n = 13). Primary endpoint was body composition change by dual X-ray absorptiometry (DXA) and computed tomography (CT).

RESULTS

Rosiglitazone resulted in slow accrual of limb fat detected by DXA (+444 +/- 186 g; p < .05) but not CT. Pravastatin had no consistent significant effects on body composition, although it reduced total and LDL cholesterol. Negative interactions were observed between pravastatin and rosiglitazone. rhGH reduced abdominal fat by CT (-31 +/- 15 cm2, 26%; p < .05) and DXA (-1597 +/- 383 g, 27%; p < .05) and increased trunk and limb lean mass (+10% and +12%, respectively). However, effects largely disappeared within 12 weeks post treatment. rhGH alone impaired insulin sensitivity but not when combined with rosiglitazone.

CONCLUSION

Prolonged rosiglitazone treatment slowly improves lipoatrophy. rhGH rapidly and selectively reduces visceral fat, although effects are short-lived; co-administered rosiglitazone abrogates rhGH-related insulin resistance.

Antiretroviral therapy and the human immunodeficiency virus--improved survival but at what cost?

Patients infected with human immunodeficiency virus are living longer since the introduction of combination antiretroviral therapy more than a decade ago - but at what cost? Highly active antiretroviral therapy has been associated with lipodystrophy and associated metabolic derangements such as dyslipidaemia, insulin resistance and diabetes. These complications are likely to contribute to an increased risk of premature and accelerated atherosclerosis with growing concern about potential cardiovascular consequences.

Metabolic complications of antiretroviral therapy in HIV-infected children

The purpose of this review is to describe the metabolic complications associated with antiretroviral therapy in HIV-infected children. As a result of extensive research over the last 10 years, there is a greater awareness and understanding of these conditions. However, in resource-limited settings, where the majority of HIV-infected children live, the prevalence and risk factors of metabolic complications are largely unknown. Limited diagnostic resources contribute to this impediment. Therapies for these conditions are still under investigation, including prevention and optimal treatment of reduced bone mineral density, osteopaenia and osteoporosis. Future research goals should be directed towards closing the diagnostic and treatment gaps between rich and poor settings.

HIV lipodystrophy and its metabolic consequences: implications for clinical practice

BACKGROUND

The introduction of highly active antiretroviral therapy (HAART) around 1996 markedly reduced mortality and morbidity from human immunodeficiency virus (HIV) infection. As life expectancy has improved, the chronic complications of HIV and HAART have become increasingly relevant.

SCOPE

This article provides an overview of the HIV-associated lipodystrophy, its pathogenesis and its clinical consequences (based on a search strategy in PubMed including literature published to November 2007).

FINDINGS

Lipodystrophy syndrome is characterized by abnormal fat distribution syndrome associated with metabolic disturbances and includes insulin resistance, deranged glucose and lipid metabolism. It is associated with increased risks of progression to type 2 diabetes and cardiovascular disease. Robust diagnostic criteria are required for lipodystrophy, and subsequent prospective cohort studies and randomized controlled trials are then required to determine the etiology and prognosis of lipodystrophy, and to evaluate therapeutic interventions for this consequence of HAART. Therapies to improve insulin resistance have been tried but they are frequently ineffective, and are limited by potential toxicity in this population. Hence, current management options for HIV associated lipodystrophy are limited and are mostly based on avoidance of risk factors and switching of antiretroviral drugs.

CONCLUSION

As the '3 by 5 strategy' of providing HIV drugs to the developing world is implemented worldwide, the numbers of patients adhering to antiretroviral medicines is dramatically increasing. One must be aware that in reducing the burden of acute retroviral disease, the treatments proposed might lead to significant rates of metabolic complications and further exacerbation of the epidemic of diabetes and cardiovascular disease.

Thiazolidinediones in dermatology

Thiazolidinediones, also known as glitazones, represent a relatively new class of medication used for glycemic control in patients with type II diabetes mellitus. These drugs interact with the peroxisome proliferator-activated receptor gamma, a member of the nuclear receptor superfamily, which in turn heterodimerizes with retinoid X receptors to stimulate gene transcription. At a physiologic level, glitazones stimulate adipocyte differentiation, enhance insulin-sensitive glucose uptake by muscle and fat cells, suppress angiogenesis, inhibit tumor cell growth, and normalize keratinocyte differentiation. They have also demonstrated the capacity to diminish inflammatory cytokine production, most notably, that of tumor necrosis factor alpha. Patients with such disparate conditions as psoriasis, hirsutism, melanoma, angiosarcoma, lipodystrophy, and necrobiosis lipoidica have benefited from the administration of thiazolidinediones. Clinicians should become familiar with glitazones as they are experiencing a burgeoning use among patients with non-insulin-dependent diabetes mellitus and have demonstrated clinical efficacy in treating certain skin conditions.

Surgical management of HIV-associated lipodystrophy: role of ultrasonic-assisted liposuction and suction-assisted lipectomy in the treatment of lipohypertrophy

PURPOSE

HIV-associated lipodystrophy is a frequent consequence of highly active antiretroviral therapy and has been associated with several metabolic disorders (increased triglycerides, hypercholesterolemia, insulin resistance) as well as altered fat distribution, including lipohypertrophy (neck, trunk, breasts) and lipoatrophy (nasolabial fold, cheek, extremities). Medical treatment of fat redistribution is usually ineffective. We evaluated the efficacy and safety of the surgical management of HIV lipodystrophy.

METHODS

We performed a retrospective review of 12 consecutive patients (3 female, 9 male; mean age, 44.4 years; mean CD4+ cell count, 554/mm3; mean body mass index, 28.9 kg/m2; mean triglycerides, 421 mg/dL; no active opportunistic infections; mean duration of HIV infection, 11.4 years) who underwent surgical management of HIV lipodystrophy at a university hospital from 2001 to 2006.

RESULTS

Surgical intervention included a combination of ultrasonic-assisted liposuction (UAL) and suction-assisted lipectomy (SAL) of the anterior neck (7 patients), posterior neck (10 patients), and trunk (2 patients); direct excision of mastoid fat pads (1 patient); direct excision of thigh lipomata (1 patient); facelift/necklift (1 patient); browlift (1 patient); fat injections (1 patient); and blepharoplasty (2 patients). Mean lipoaspirate volume was 701 mL (range, 270-1400 mL). Complications and sequelae included seroma (1 patient), ecchymosis (1 patient), need for revision (2 patients), and recurrence (3 patients) but did not include nerve injury, fat necrosis, skin loss, or infection. Although all patients reported improvement in form and function, UAL/SAL of the anterior neck had limited efficacy in 3 of 7 patients. UAL/SAL of the cervicodorsal fat pad was initially successful in 10 of 10 patients, but 3 patients developed partial late (>1 year) recurrence, all associated with weight gain. Mean follow up was 30 months (range, 1-66 months).

CONCLUSIONS

Despite the potential for recurrence, surgical management of HIV-associated lipodystrophy is efficacious with minimal morbidity. UAL/SAL is particularly beneficial in reducing the cervicodorsal fat pad, whereas facelift and necklift may be necessary to adequately address anterior neck lipohypertrophy.

Immediate versus delayed polyalkylimide gel injections to correct facial lipoatrophy in HIV-positive patients

OBJECTIVE

To evaluate the safety and efficacy of polyalkylimide gel (PAIG) in the treatment of HIV-associated facial lipoatrophy.

DESIGN

A randomized, open-label, single-centre study.

METHODS

HIV-positive individuals with facial lipoatrophy (based on physician assessment) were randomly assigned to immediate (weeks 0 and 6) or delayed (weeks 12 and 18) PAIG injections administered into the subcutaneous plane. Outcome measures included a change in facial lipoatrophy severity scores (five-point scale), adverse events, photographic assessment, and changes in quality of life (QoL), depression and anxiety using validated surveys.

RESULTS

Thirty-one patients (median age 48 years, 97% male) were enrolled and completed 48 weeks of follow-up. Overall, the median volume of product injected bilaterally was 16.0 ml. Adverse events, including swelling, redness, bruising and pain, were mild, and resolved after a median of 3 days. There were no cases of necrosis, nodules or infection. Compared with patients randomly assigned to delayed treatment, patients in the immediate therapy group had significantly lower physician-rated facial lipoatrophy scores (0 versus 2; P < 0.0001), improved QoL (P = 0.01), and lower anxiety (P = 0.02) at week 12. At week 48, median physician and patient facial lipoatrophy scores were 0 and 1, respectively, for the entire cohort, and were not significantly different between the groups. Significant improvements in patient anxiety (P = 0.001) and depression (P = 0.01) were observed from baseline to week 48.

CONCLUSION

Treatment with PAIG was effective and safe and led to improvements in facial lipoatrophy grading, QoL, anxiety and depression scores in HIV-infected patients with facial lipoatrophy.

Experience with Bio-Alcamid, a new soft tissue endoprosthesis

Bio-Alcamid (Polymekon, Italy) is a relatively new, injectable soft tissue endoprosthesis that is recommended for correcting soft tissue defects and contour deformities. It consists of 96% water and 4% synthetic polymeric polyalkylimide, and once injected becomes enclosed within a thin collagen capsule.

MATERIALS AND METHOD

We have treated a selected series -- 34 patients, 57 anatomical sites treated in 64 treatment sessions, with a range of 2.5 ml to 110 ml injected per site per injection. The indications have been as diverse as anti-retrovirus treatment associated facial lipoatrophy, pectus excavatum and post-breast reconstruction contour deformities. The patients were followed up in clinics and through a postal questionnaire survey.

RESULTS

The longest follow up we have now is over eighteen months. The results have been uniformly good and satisfactory to both patients and the surgeon. The patients tolerated the treatment very well under local anaesthesia. The questionnaire survey showed universally high degrees of satisfaction. The biggest advantages of Bio-Alcamid over other filler injections have been permanency of volume correction and a very natural soft feel of the treated areas. Many patients required a single treatment only to correct significant volume defects.

CONCLUSION

In our experience, Bio-Alcamid is safe and fulfils most of the criteria of an ideal injectable filler material.

Uridine Supplementation for the treatment of Antiretroviral Therapy-Associated Lipoatrophy: A Randomized, Double-Blind, Placebo-Controlled Trial

Background

Highly active antiretroviral therapy (HAART) is associated with loss of subcutaneous fat (lipoatrophy) presumably due to mitochondrial toxicity of nucleoside reverse transcriptase inhibitors. In vitro, uridine abrogates thymidine analogue-induced toxicity in adipocytes.

Methods

A total of 20 patients with HAART-associated lipoatrophy were randomized to receive either a dietary uridine supplement (36 g three times a day for 10 consecutive days/month) or placebo, for 3 months. Body composition was measured using dual energy X-ray absorptiometry, magnetic resonance imaging and proton spectroscopy. Data are mean ± standard error of mean.

Results

The mean increases in limb fat (880 ±140 versus 230 ±270 g; P<0.05), intra-abdominal fat (210 ±80 versus -80 ±70 cm3; P<0.05) and total body fat (1,920 ±240 versus 240 ±520 g; P<0.01) were significantly greater in the uridine than in the placebo group. Within the uridine group, the changes from baseline to 3 months were statistically significant in total limb fat ( P<0.001), intra-abdominal fat ( P<0.05) and total body fat ( P<0.001). The proportion of limb fat to total fat increased from 18% to 25% ( P<0.05) in the uridine group. Liver fat content and lean body mass remained unchanged in both groups. High-density lipoprotein-cholesterol concentrations decreased in the uridine and increased in the placebo group, whereas fasting serum insulin concentrations did not change. Uridine supplementation was well tolerated and the virological effect of HAART was not affected.

Conclusion

Uridine supplementation significantly and predominantly increased subcutaneous fat mass in lipoatrophic HIV-infected patients during unchanged HAART.

Dermatologic adverse effects of antiretroviral therapy: recognition and management

Despite the decrease in opportunistic infections associated with HIV in the highly active antiretroviral treatment (HAART) era, a significant number of patients still present with skin pathology, some of which can be attributed directly or indirectly to antiretroviral therapy. The non-nucleoside reverse transcriptase inhibitors exhibit a class effect with regard to skin adverse manifestations, and the spectrum of disease can vary from a mild morbilliform rash to Stevens-Johnson syndrome. Certain protease inhibitors are associated with rash, and indinavir causes retinoid-like manifestations such as paronychia, alopecia, ingrown toe-nails, and curling of straight hair. Abacavir, a nucleoside reverse transcriptase inhibitor, is notorious for causing a hypersensitivity reaction in select patients. The fusion inhibitor enfuvirtide causes injection-site reactions in the overwhelming majority of patients, although a new method of delivery has decreased the rate and severity of these reactions. A syndrome of lipoatrophy with or without lipohypertrophy, often termed lipodystrophy, has been described in patients receiving HAART. Potential management of lipoatrophy includes switching antiretrovirals and surgical treatment with facial fillers. Lastly, skin manifestations of the immune reconstitution inflammatory syndrome, including herpes zoster and warts, must be recognized and treated accordingly. In the evaluation of the individual HIV-infected patient receiving antiretroviral therapy who presents with a skin disorder, clinicians should consider the CD4 cell count as a marker of the degree of immunodeficiency, the specific antiretrovirals used, and the timing of the initiation of antiretroviral therapy in order to formulate a rational differential diagnosis. Management should be individualized based on the specific drug that is implicated and the severity of the reaction.