Clinical Manual for Management of the HIV-Infected ... - myCME.com

Pharmacologic Measures
Recombinant Human Growth Hormone
Treatment with recombinant human growth hormone
(rHGH), 3-6 mg/d for 12 weeks followed by
maintenance therapy with lower doses of 1-2 mg/d, has
been shown to reduce visceral fat with minimal impact
on peripheral fat wasting. However, the high cost of
rHGH, the high rate of adverse effects (including
insulin resistance), and the frequent recurrence of
morphologic abnormalities once rHGH is discontinued
have resulted in a limited role for this treatment.
Insulin-Sensitizing Agents
In diabetic and non-HIV lipodystrophy, treatment
with thiazolidinediones may decrease visceral fat,
increase peripheral fat, and improve glycemic control.
Unfortunately, studies of rosiglitazone as treatment for
lipoatrophy in HIV-infected patients have shown mixed
results. Some small studies have reported improvement
in peripheral fat loss; however, a larger, 48-week
randomized trial of rosiglitazone in HIV-infected
patients with lipoatrophy found no improvement in fat
mass. Therefore, rosiglitazone cannot be recommended
currently for the treatment of lipoatrophy.
Metformin has been somewhat effective in treating
lipoaccumulation in patients with insulin resistance, but
may cause worsening of lipoatrophy. Metformin should
not be given to patients with an elevated risk of lactic
acidosis.
Studies of insulin-sensitizing agents continue.
Plastic and Reconstructive Surgery
Various techniques have been investigated, but generally
have limited applicability and efficacy. These include
liposuction and breast reduction for lipoaccumulation,
and cheek implants and autologous fat transfer for facial
lipoatrophy. Poly-L-lactic acid (Sculptra, New-Fill) is
approved by the U.S. Food and Drug Administration
as a treatment for facial lipoatrophy. This injectable
material has shown to good cosmetic results, at least in
the short term.
Although plastic surgery can help some people with
lipodystrophy, the treatments are expensive, may need
to be repeated, and usually are not covered by private or
public-payer sources. In some cases, they may be only a
temporary solution, because abnormalities may reappear
after treatment.
Section 4—Complications of Antiretroviral Therapy | 4–3
Patient Education
♦
♦
♦
♦
Instruct patients who are receiving ARV
medications to inform their health care providers if
they notice changes in the shape or appearance of
their bodies.
Review the importance and benefits of ART and
assess adherence to the regimen.
For patients with lipoaccumulation, recommend
aerobic and resistance exercise to build muscle and
reduce fat. Assess resources in your area for safe
muscle-strengthening possibilities.
If weight reduction is needed, refer to a dietitian for
consultation. Remind the patient that quick weight
loss diets may result in excessive muscle loss.