VADEMECUM FOR HIV PATIENTS ADDENDUM #3 PREVENTION AND MANAGEMENT OF LIPODYSTROPHY
Lipodystrophy, or "lipo" for short, is a collection of body shape changes in people taking antiretroviral medications. "Lipo" refers to fat, and "dystrophy" means bad growth. These changes include fat loss, fat deposits, and metabolic changes. Fat loss occurs in the arms, legs or face
(sunken cheeks). This may be the most common feature of lipo. Fat deposits can show up in the
stomach, the back of the neck (a "buffalo hump"), the breasts (in both men and women) or other
areas. Metabolic changes can include increases in blood fats or lactic acid. Some people get "insulin
resistance." There is no clear definition of lipo. As a result, health care providers report that
between 5% and 75% of patients taking antiretroviral medications have some signs of lipo. Most
researchers think the rate is about 50%. We here focus on the first two aspects of lipodistrophy: fat
Lipoatrophy Definition - It is the loss of fat in the face, arms, legs or butt. Although it generally does not
endanger the physical health, it can be exceedingly damaging to the sense of self and even to the
ability to function in public. Widely identified with the "AIDS look," severe facial lipoatrophy can
"out" a person with HIV, leaving the person vulnerable to stigma, discrimination and worse.Prevention - Avoid stavudine (d4T) and zidovudine (ZDV, AZT) or pre-emptively switch away
o Switch d4T or ZDV to abacavir (ABC) or tenofovir (TDF): only antiretroviral
modification proven to partially restore subcutaneous fat; increase in total limb fat
! Note: possible risk of other toxicities from new drugs.
o Switch to regimen not including nucleos(t)ide reverse transcriptase inhibitors
(NRTIs): increase in total limb fat ~400-500g/year.
! Note: may increase risk of dyslipidaemia.
! Note: less data on virological safety.
- Surgical intervention offered for relief of facial lipoatrophy.
- Pharmacological interventions to treat lipoatrophy have not been proven to be effective and
o Pioglitazone - possibly beneficial in patients not taking d4T.
o Rosiglitazone and Pioglitazone - improvement in insulin sensitivity.
o Rosiglitazone: increases in blood lipids and possible ischaemic heart disease.
Lipohypertrophy Definition - Lipodystrophy-related fat gain, which doctors call "lipohypertrophy," is the opposite of lipoatrophy (fat loss). The most common parts of the body that fat gain strikes are the belly, breasts (especially for women) and neck.
- Weight gain expected with effective antiretroviral therapy and reflect “healthy” response. - Weight reduction or avoidance of weight gain may decrease visceral adiposity.
- Diet and exercise may reduce visceral adiposity:
o Limited data, but possibly reduction of visceral adipose tissue and improvement in
insulin sensitivity and blood lipids, especially in obesity associated with lipohyperthrophy.
o No clear indication of the degree of diet and/or exercise needed to maintain reduction
- Pharmacological interventions to treat lipohypertrophy have not been proven to provide
long-term effects and may introduce new complications. In particular:
! May worsen subcutaneous lipoatrophy, may worsen insulin resistance.
! Tesamorelin (growth hormone realising factor), not currently licensed in
Europe, was shown to reduce visceral adipose tissue volume.
! Decreases visceral adipose tissue in insulin resistant people.
o Surgical therapy can be considered for localised lipomas/buffalo humps:
Authors: Associazione e Fondazione Nadir Onlus - Via Panama n. 88, 00198 Roma, Italy. Source: EACS Guidelines, Version 5 – November 2009, modified and adapted by Nadir. Thanks to Boehringer Ingelheim International GmbH for supporting this publication.
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