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4–2 | Clinical Manual for Management of the HIV-Infected Adult/2006
pad and facial, neck, or breast enlargement. Examine the
face and extremities for subcutaneous fat loss (eg, in the
cheeks, temples, limbs, and buttocks).
Review laboratory history (glucose, lipid panel), to identify
other metabolic disorders. (See chapters
Dyslipidemia and Insulin Resistance and Hyperglycemia
on Antiretroviral Therapy.)
A: Assessment
No uniform standard criteria are available for defining
or grading lipodystrophy in clinical practice. Clinicians
must base their assessment on physical examination (for
characteristic body-shape changes) and lipodystrophyassociated
symptoms and psychological consequences.
In research settings, modalities such as dualenergy
x-ray absorptiometry (DEXA), computed
tomography (CT), and magnetic resonance imaging
(MRI) have been used to characterize lipodystrophy.
Anthropometric measurements may be made in the
clinic by trained personnel (eg, nutritionists), but do not
measure visceral fat directly. Although measurements
such as waist circumference cannot be used to assess
lipodystrophy, they have been validated (in non-HIVinfected
individuals) as an assessment of cardiovascular
risk. Bioelectrical impedance analysis (BIA) does not
measure regional body composition and thus is not used
to measure abnormal body-fat changes.
P: Plan
Laboratory
Check for other metabolic abnormalities associated
with the use of ART, such as dyslipidemia and impaired
glucose metabolism. See chapters Dyslipidemia and
Insulin Resistance and Hyperglycemia on Antiretroviral
Therapy for further information about workup and
treatment.
Evaluate the effect of body-shape changes on the
patient’s self-esteem, medication adherence, and
interpersonal relationships. Refer the patient for
psychological or adherence support and counseling, if
indicated. If the patient is distressed enough to consider
discontinuing or interrupting ART, review with the
patient any gains he or she has made on ART and
discuss treatment options (see below). In some cases the
patient may insist on discontinuing ARV medications;
in this situation, carefully review the risks and benefits
of treatment interruption, as well as the alternatives to
discontinuing treatment.
Treatment
Consistently effective treatments for lipodystrophy have
yet to be identified. In general, patients with marked or
severe lipodystrophy have shown poor or inconsistent
responses to interventions. The best approaches to
lipodystrophy are prevention and early intervention.
Clinicians can help to prevent lipodystrophy by
avoiding, whenever possible, ARV agents known
to confer a greater risk of this disorder (particularly
stavudine). All patients who take ARVs should
be monitored carefully for the development of
lipodystrophy. If lipodystrophy is noticed, intervention
should be initiated, if possible.
The optimal management of lipodystrophy is not
known, although the following approaches can be
considered. Also consider referring the patient to
clinical studies of lipodystrophy treatment.
Drug Substitutions
Avoiding thymidine analogue NRTIs, particularly
stavudine, and avoiding the NRTI combination
stavudine + didanosine have been shown to reduce
the risk of lipoatrophy. In patients with lipoatrophy,
modest long-term improvement has been demonstrated
after switching from thymidine analogues (stavudine
and zidovudine) to nonthymidine analogues (such as
abacavir or tenofovir) or to NRTI-sparing regimens.
Before switching therapies, carefully assess the potential
risk to the patient’s long-term HIV management.
Nonpharmacologic Measures
Diet
The effects of diet on lipodystrophy have not been
evaluated thoroughly. If overall weight reduction is
needed, recommend dietary changes and exercise. Avoid
rapid weight loss plans, as lean body mass is often lost
disproportionately. Refer to a dietitian, to help the
patient decrease his or her intake of saturated fat, simple
sugars, and alcohol.
Exercise
Regular, vigorous cardiovascular exercise may help
control central fat accumulation, whereas musclebuilding
(strength training) will improve the ratio
between fat and muscle. Some studies of exercise
have shown a reduction in visceral fat accumulation
with minimal or no changes in peripheral lipoatrophy.
Moderate aerobic exercise should be encouraged in all
patients.