AEGiS-ATDN: Big Fat Controversies: What is it? Where did it come from? How can I get rid of it?

Important note: Information in this article was accurate in 2002. The state of the art may have changed since the publication date.

Big Fat Controversies: What is it? Where did it come from? How can I get rid of it?

Information Bulletin #16 - August 2002

Loss of fat in the arms, legs and in the face, and increased fat in the belly, breasts, neck and back are common problems for people on HAART. This is called Lipodystrophy. These problems are often coupled with metabolic disorders, such as high cholesterol and triglyceride levels, diabetes, all of which can potentially lead to serious health problems with your thyroid, pancreas, heart, and liver. The changes in body fat, such as having a huge belly, sunken cheeks and thin legs and arms, can be very hard to live with for psychological reasons as well. Several studies presented at the conference tried to define lipodystrophy, figure out what actually causes it, and determine how to manage it. Not surprisingly, the studies presented at the conference did not provide much agreement regarding any of these three objectives, with the exception that taking medications to lower blood fat levels is a common, often successful practice. Discuss these options with your doctor.

How to define lipodystrophy? The FRAM (Fat Redistribution and Metabolism) study compared a large group of HIV+ people to an HIV- control group and found that loss of fat in the arms and legs is much more common in HIV+ individuals. They also found that fat accumulation on the neck and back, contrary to common clinical observations, was not more common in the HIV+ group. In addition, older people in both groups tend to have more fat in the belly, suggesting age as a factor contributing to this condition. It's not clear why the results of this study contradicted what many doctors and patients are experiencing. One possible explanation is that the HIV- control group came from a separate heart disease study. They were heavier than the HIV+ group in general.

What causes lipodystrophy? One study compared people using different combinations of the three classes of anti-HIV drugs (protease inhibitors (PIs), nucleoside reverse transcriptase inhibitors (NRTIs) and non- nucleoside reverse transcriptase inhibitors (NNRTIs). The trial looked at people who have been on the same HAART regimen for at least a year and a half, with follow up of up to 3 years. The results indicated that a protease inhibitor-containing regimen has a greater chance of causing fat accumulation in the belly, but otherwise was no different than regimens containing all NRTIs or regimens with an NNRTI. Overall, about 25% of study participants reported moderate or severe loss of fat, 15% reported fat gain, and 10% reported both. Cholesterol, triglycerides, glucose, and all other metabolic tests were the same in the three groups. It is not certain what, if any, conclusion can be drawn from this. All the patients in the study were on the combination of d4T and ddI, which has been linked with lipodystrophy in several previous studies.

How to manage lipodystrophy? One study switched patients from a stable protease inhibitor based regimen to another non-PI combination, using abacavir (Ziagen), efavirenz (Sustiva) or nevirapine (Viramune). The study looked at several blood values to see if improvements in levels of triglycerides or cholesterol were seen. All three treatment arms had significant improvements in the cholesterol levels, but no changes in insulin resistance. Efavirenz and nevirapine were able to raise the level of HDLc (good cholesterol), efavirenz and abacavir were able to lower the LDLc (bad cholesterol) level. Only the participants who switched to nevirapine saw an improvement in triglyceride levels. Switching from a PI containing regimen to another regimen containing nevirapine, for example, may help to manage lipodystrophy, along with lipid lowering drugs, diet and exercise.

These are all issues that need to be discussed with your doctor. We can't tell you what drug might work best for you at lowering triglycerides, for example, but you doctor knows all about it. For backup information, give us a call, or visit our new web site at (www.atdn.org)

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