WELLNESS STARTS WITH AWARENESS - CD8 T cells - The Body

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hands, and fi ngers. If I slept with one arm under the pillow, that arm immediately fell asleep. Th e tingling and carpal-tunnel-like symptoms continued sometimes all day. At one point, I cut down my dose of tesamorelin for a couple weeks. Th e tingling disappeared, but returned once I started again on the higher dose. How tesamorelin stacks up against Serostim It’s easy to be impressed by the research on tesamorelin. Several large Phase 3 clinical trials have been completed and they are impressive. People taking 2 mg of tesamorelin lost at least 11% of their vat at week 26. At week 52, people lost up to 18% of their vat. According to the FDA, any vat reduction of at least 8% was good enough. For perspective, compare the numbers for both tesamorelin and somatropin. Aft er 26 weeks on 2 mg of tesamorelin taken daily, patients lost about 20 square centimeters from their belly when compared to placebo. Most of the eff ect occurred in the fi rst 13 weeks of treatment. On the other hand, aft er 12 weeks on 4 mg of somatropin taken daily, patients also lost about 20 square centimeters from their belly when compared to placebo. In terms of safety, somatropin falls short when compared to tesamorelin. In a 12-week study of somatropin, about one-in-four patients were forced to stop or lower their dose because of intolerable side eff ects, such as swelling or glucose problems and diabetes. For tesamorelin, side eff ects were no more common than with placebo and showed no signs of prompting glucose issues. “We see the advantage in the safety profi le,” said Andrea Gilpin, vice president of investor relations and communications at Th eratechnologies (makers of tesamorelin). Newcomers to the HIV market, the small Canadian biotech plans to fi le for FDA approval by end of 2008. “We feel we have a good product and just need to take it to the fi nish line.” But whose fi nish line? Understandably for Th eratechnologies, the end game is FDA approval. But for patients, the predicament of tesamorelin and somatropin is what happens aft er the drug is stopped. For people who took tesamorelin for 26 weeks and then stopped, they regained nearly all their vat within six months. Th e same holds true for Serostim, except some unlucky patients gain back vat and get stuck with diabetes. “What’s the endpoint?” said Amorosa about the prospect of growth hormone as a viable treatment for vat. “What happens aft erward? Do you leave someone on medication for years?” She noted that growth hormone treatment isn’t practical for the majority of people with HIV. Furthermore, she cautioned that tesamorelin has not been compared to intensive diet and exercise. The boring truth about diet and exercise As a kid, I read the novel Flowers for Algernon. Th e main character, Charly, is the fi rst person to test a medical procedure that improves intelligence. Charly grows smarter, even brilliant at one point aft er surgery. But with time, he reverts back to his belowaverage IQ. For me, the prospect of reverting back to my old appleshaped self within six months is depressing. I wonder, is it better to have lost vat and gained it back, than to never have lost vat at all? 32 Over the years, a few scattered studies have looked at how exercise aff ects vat. In 2007, a 16-week clinical trial studied the eff ects of a supervised high-intensity exercise program on vat, cholesterol, and glucose control among people with HIV. Th e exercise program consisted of cardio and strength training—almost identical to the program my trainer Brian had imposed on me. Th e study was small, nine people started and only fi ve people fi nished. But the results were impressive. Researchers saw statistically signifi cant decreases in vat, triglycerides, and improvements for insulin sensitivity. Th e researchers concluded that a larger study of exercise intervention is justifi ed. Unfortunately, there isn’t money to be made from exercise. Th ere is no large exercise organization to lobby for its benefi ts. So, vat interventions will continue to come in the form of pharmaceutical pills and shots. To maintain less fat and more muscle, I fi gure the key is diet and exercise. I plan to continue my three-times weekly workouts with Brian. But calorie restriction has never been easy for me, especially without cigarettes. “Honestly, the most important thing is not to smoke,” said Amorosa. “A lot of people smoke because they want to keep thin. In our patients who have HIV, there’s a lot of smoking. It’s worse in terms of risk factors for heart attack and everything else. Even if people were to gain fi ve pounds from not smoking, that would be worth it. If they care about their health, that’s number one.” At the end of the day, she said, there are two primary issues people should consider. Th ere’s the physical issue of being comfortable in your own skin, how you look. Th e other is the potential for bad health outcomes, like heart disease and diabetes. So what’s a person to do? “It’s boring, but it’s diet and exercise,” said Amorosa. People should adopt healthy eating habits that are sustainable over time. People need to learn exactly what that means. She suggested limiting calories, but especially those from sugar and alcohol. She also suggested that Weight Watchers has a solid track record for long-term weight loss. “Th inking about pharmacologic interventions,” said Amorosa, “compare the cost of tesamorelin to the cost of a membership at Weight Watchers.” Aft er a year on tesamorelin, I can say that tesamorelin reduces vat and increases muscle. No question. Is tesamorelin more eff ective than Serostim? Probably. Tesamorelin certainly is safer—so far anyway. Does the vat return when treatment stops? Yes, that’s what the research says. What am I going to do without growth hormone? I’m going to choose the relentlessly optimistic attitude about fi tness that my trainer drilled into me. I will continue to work out three days a week. As for my Tuesday nights, I quit group therapy. In its place, I’ve joined Weight Watchers. Maybe it’s hokey, but I don’t care. For long-term health, it’s important to stay as lean as possible. Aft er all, I was blessed enough to survive HIV, the least I can do is take really good care of the rest of me. e Brett Grodeck is the author of The First Year—HIV: An Essential Guide for the Newly Diagnosed, and a former editor of Positively Aware magazine. PA • September / October 2008 • tpan.com • positivelyaware.com Positively Aware
Methadone wellness Sarz Maxwell, M.D., is a psychiatrist with the Chicago Recovery Alliance, and before that, she was with the Center for Addictive Problems methadone clinic in Chicago. Enid Vázquez: So, this is an issue about wellness. What do you want to say about methadone and wellness? Sarz Maxwell: Let me put it in the context of what methadone does. And to do that you have to understand what heroin addiction is. Our brains produce natural opiates called endorphins. We’ve all heard of them. For some reason we don’t understand, in people who will become addicted to heroin, the brain stops making enough endorphins. So for someone with this condition, taking opiates—whether it’s heroin or methadone or whatever—is exactly the same as someone with diabetes taking insulin. So not only does methadone promote wellness, but in people who have this disease of endorphin deficiency, which usually we see as heroin addiction—that’s the way it manifests itself, that’s how we make the diagnosis— methadone is necessary to wellness. Abstinence-based treatment for opiate addiction—it doesn’t matter what the treatment is, whether it’s three years of intensive residential, whether it’s intensive outpatient, whether it’s 12-step based— any treatment for opiate addiction that does not include methadone has a relapse rate of 90%. Nine-o. That would be like saying, “Well, 10% of people who are on just a protease inhibitor as opposed to a HAART [highly active anti-retroviral therapy, for HIV] regimen do okay, so let’s just start with that.” It’s insane. But … talking about methadone and wellness is a whole new slant on it because we don’t think about addiction as treatment in terms of wellness. We think about it in terms of goodness or badness. PA • September / October 2008 • tpan.com • positivelyaware.com Positively Aware EV: That’s great, because we’re going to go there … all the stigma, all the discrimination. SM: That’s a good way to lead off. That’s one of the problems, is that we don’t talk about methadone and wellness, we talk about methadone as goodness or badness. That’s because we don’t conceptualize addiction as a disease. We talk about it as a disease, but that’s bullshit. We don’t act like it’s a disease. In what other disease would I as a doctor say to someone, “Okay, I’ve had you in treatment, but you’re still sick so … get out of here.” It’s insane. How many people with diabetes are able to do without insulin? I keep bringing up that analogy because it is exact. Heroin addiction is caused by a deficiency of endorphins in the brain, just like diabetes is caused by an insulin deficiency in the pancreas. There are some people who develop diabetes late in life because they had some sort of drug interaction, or because they’re pregnant, or because they’re overweight. And for those people, they may be able to manage their diabetes once they take care of that underlying condition. They may be able to manage it through just diet. But for people with the disease, you’re not talking to them about getting off of insulin! People ask, “Isn’t methadone harder to get off of than heroin?” I don’t understand that! How hard is HAART to get off of? But we don’t talk to people about getting off of HAART. “This is something you’re going to take for a couple of years and then when your HIV is all over, we’ll wean you off it.” And of course, people say, “But they want to get off their methadone.” Doctor and advocate Sarz Maxwell on the science— and madness Interview by Enid Vázquez Of course! How many people want to take HAART? All I can do is rant, because the questions don’t have any answers, because it’s all fucked up. People who are addicted to opiates, the problem is not that they use opiates. It’s that they need opiates. They don’t function without them. They can’t function without them. And so the only options that are given to them are to not function because they’re not getting their opiates or to get their opiates through a system that doesn’t allow them to function. How many people with diabetes are able to do without insulin? EV: I remember these horrific stories on a methadone listserv years ago. The other doctor at your clinic was on it. SM: Marc Schinderman [of Center for Addictive Problems, in Chicago, Downers Grove, Illinois, and Westbrook, Maine]. EV: People had to get to the clinic within these certain times, and go each and every day. The people in California were worried that if an earthquake occurred, they wouldn’t be able to get their medicine. SM: We still conceptualize methadone as candy, that we give to good little addict s and withhold from bad little addict s, and if they can’t get their candy today, oh well. Methadone is still working off rules that were established 25 years ago—just like everything else in medicine. Nothing has changed in 25 years, you know? But the rules are that for the first 90 days, people must come to the clinic six days a week. After 90 days they are eligible to ap- 33
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Page 15 and 16: AS PART OF HIV COMBINATION THERAPY:
Page 17 and 18: Photo © Russell McGonagle Drug lab
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Page 25 and 26: ATRIPLA. The #1 prescribed complete
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